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MEDICAL.WASTE TRACKING FORM NUMBER <br /> ®• it:ytl@' IN CASE OF EMERGENCY CONTACT:CNEMTREC t <br /> STANDAIIDMANIFEST 001•10,40"D <br /> @® Ster+rft"bwm.ed3Q1 - 14 ST0 cE o.z 2 <br /> 1,Generator's Name,Address and Telephone Number <br /> HE <br /> ATTNt Alice SQuligne i l l i i011 <br /> CEANNU MEDICAL CEUM 7 <br /> 701 E COAMM ST <br /> STOCM1, C4 95202- 2628 <br /> 209 944-4710 4/7/2017 <br /> CUSMUM NUMBER 6017 53-002 • <br /> 2A.DESCRIPTION OF WASTE 20• CONTAINER TYPE 2C. NO.OF 20 VOLUME <br /> UN3291,Regulated Medical Waste.mo,s.. CONTAINERS <br /> 6.2,PGII TH57 - 90 tial Tub (Bio) (12 cat ft) Cu Ft. <br /> UN3291 i 6.22.P6II Regufased Medical Waste,n o.s. 7849 - 37 Gal Tub (H30' (4.9 cru tt) Gu Ft. <br /> ® UN3291,Regulated Medical Waste,n.o.s., �y <br /> 6.2,PGII T814 - 44 Gil Tub(Bio) (5.9 cu tt) (/ ti' a `fru Ft. <br /> UN3291 Regulated Medial Waste.e.0.s. <br /> Q 5821 - 20 t+aa. Tub(Rio) (2.7 cu tt) <br /> 6.2.PGII Cu Ft. <br /> W UN3291,Regulated Medical Waste,nos.. <br /> W6.2,PGII T915 - 20 Gal Tub (Path) (2.7 cu tt) Cu Ft. <br /> town Regulated Medical Waste,o.o.s., <br /> 6.2,PGIi TY1S - 20 Gal Tub (Chemo) 42.7 CN tQ Cu FL <br /> UN3291,Regulated Medical Waste,n o.s., <br /> 6.2,P011 Cu FL <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2.PGI1 Cu FL <br /> i Pharmaceutical tta <br /> 3.Generator's Certification:'I hereby declare that the contents of this consignment are fully and accurately 2— + V Cu FL <br /> described above by the proper shipping names,and aro classified,packaged,marked and labehed/placarded,and <br /> are in all respects in proper condition for transport accords applicable International and national governmental ulatio " <br /> i I !Pdntedlryped Name Signature Date <br /> 7 tt <br /> 4.TRANSPORTER 1 ADDRESS: <br /> �+ ADDRE: PAhpoPnSeraRd:e � 275 0 <br /> SteriGle, Inc. <br /> rs: <br /> �c 4135 Vwt St,13ft Ave. <br /> 9'lceenc,Ce 93722 This 1s a rorig Shipment <br /> a q TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> r <br /> Pdnb ype Name �ew'f i6' y' Tamar Signature Date ¢ 1 r <br /> 6. 4 1 RIP MP <br /> INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone p: <br /> CC Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: PIS e: <br /> CC Applicable Permit Numbers: <br /> I <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of meccal waste as described above. <br /> PdnNtypo Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> d waym, eI Q to: N UT <br /> y <br /> GA. Facility: 0 ea.Alternate Facility: sC.Alternate Facility: W.Alternate Fxsity: <br /> JSterlClOs;Inc Ina Inc Inc <br /> L oto W. 9= N T <br /> N � CITY,UT ,CA WEST 1345 DOOM DM Ste c CN,CA SM <br /> (5159)275 (80t)936. 1556 (510)so.1781 I 1 <br /> ILI TS3t, V) St ,P-115 <br /> eI- ,,DAL ,VED <br /> Pji TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> I- $ receivedithe above irndicated wastes in accordance with the requirement outlined in that authorization. <br /> PrWype Name Signature Date <br /> It3��J� <br /> ORIGINAL <br />