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MEDICAL WASTE TRACKING FORM NUMBS
<br />*Go Stericyclee IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-234-0051
<br />0.0 a a
<br />Y 9I received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name
<br />Signature
<br />LEAVE AT GENERATOR
<br />Date
<br />1. Generator's Name, Address and Telep%one Number
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,CONTAINERS
<br />LIN 3291, PG 11
<br />Cu
<br />REGULATED MEDICAL WASTE, ri.o.s., 6.2,
<br />LIN 3291, PG 11
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />0
<br />UN 3291, PG 11
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />UN 3291, PG 11
<br />Cu
<br />III
<br />REGULATED MEDICAL WASTE, ri.o.s.,6.2,
<br />LLIZ
<br />UN 3291, PG 11
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />LIN 3291, PG 11
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />LIN 3291, PG 11
<br />1
<br />Cu
<br />Cu
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® Cu
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects �er condition inqfor transport, according to applicable international and national governmental regulations."
<br />j
<br />XPrinted/Typed Name Signature Date
<br />IX
<br />4. TRANSPORTER 1 ADDRESS: Phone #:
<br />LU
<br />I-
<br />Applicable Permit Numbers:
<br />IX
<br />0
<br />CL
<br />Z
<br />(L
<br />TRANSPORTERXERTIFICATION.: Receipt of medical w aste as degER&66 above:`
<br />Print/Type Name Signature —, Date
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone #:
<br />c4w
<br />IX -
<br />Applicable Permit Numbers:
<br />Uj<o:
<br />liBui
<br />Lu _j
<br />OM
<br />E
<br />Ix
<br />zZ
<br />J -u I
<br />INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />,
<br />93
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phony #:
<br />WW -!R W
<br />Applicable Permit Numbers:
<br />maw
<br />W
<br />020
<br />MIX
<br />MIX
<br />INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as'described above.
<br />ZUJ<
<br /><
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />❑ 8A. Designated Facility:
<br />F-1 81B. Alternate Facility:
<br />Alternate Facility:
<br />El 8D. Alternate Facility:
<br />8E. Alternate Facility:
<br />E
<br />Autoclavable Treatment
<br />Autoclavable Treatment
<br />Autoclavable Treatment
<br />Incineration Treatment
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />Stericycie, Inc.
<br />2775 E. 26th Street
<br />1345 Doolittle Drive, Suite C
<br />4135 W. Swift Avenue
<br />90 North 1100 West
<br />Vernon, CA 90023
<br />San Leandro, CA 94577
<br />Fresno, CA 93722
<br />North Salt Lake, UT 84054
<br />E
<br />.0 1
<br />a
<br />(323) 362-3000
<br />(510) 562-1781
<br />(559) 275-0994
<br />(801) 936-1555
<br />Class V Incineration
<br />9 E
<br />9
<br />MWTF Permit # P-115
<br />MVVTF Permit# TS -31
<br />MWTS/0ST Permit# TS/OST-22
<br />Permit #91-02
<br />MVVTS Permit# P-6
<br />MWTS Permit# TS/OST-25
<br />Treatment by incineration
<br />A HE
<br />TREATMENT FACILITY. I certify
<br />that I have been authorized
<br />by the aDDlicable state naenrv'
<br />to accent iinti-PRtk-ri mi-riin:41 wnztpq
<br />:;nri that I haves
<br />Y 9I received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name
<br />Signature
<br />LEAVE AT GENERATOR
<br />Date
<br />
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