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V. Steric cle 21 <br />® y Customer Number: <br />MEDICAL WASTE TRACKING FORM z <br />1. Generator's Name and Mailing Address 2. Tracking Form Number O <br />P <br />975 1Ad� F a LL 001566 <br />N <br />4. State Permit or ID No. Z <br />3. Telephone No. ) 33"11 <br />5. Transporter's Principle Name & Mailing <br />Address <br />Ryder Distribution Resources, Inc. <br />3600 N.W. 82nd Avenue <br />Miami, FL 33166 <br />EPA or State Med Waste ID No. <br />6. Telephone Number. <br />(909) 799-8500 <br />7. Transporter Permit or <br />ID No. <br />3120 <br />8. Destination Facility Name & Address 9. Telephone Number <br />STERICYCLE, INC. (909) 799-8500 <br />10390 ENTERPRISE DRIVE 10. State Permit or ID No. <br />REDLANDS, CA 92374 99-00060-P <br />11. US EPA Waste Description <br />A. Regulated Medical Waste S <br />B. Regulated Medical Waste L <br />C. Special Anatomical Waste <br />D. Other <br />12. Total No.f 13. Total Weight <br />Containers I or Volume <br />14. Special Handling Instructions and Additional Information <br />3 Z= (�- �� 13 <br />15. Generator's Certification: <br />Under penalty of criminal and civil prosecution for the making or submission <br />of false stat s1 i sions, I declare on behalf of the <br />generator <br />that the contents of this consignment are fully and accurately described <br />above and are classified, packaged, marked, and labeled in accordance with <br />all applicable State and Federal laws and regulations, and that I have been <br />Date <br />Trailer # <br />Receiver # 4;Uo? <br />INSTRUCTIONS FOR COMPLETING MEDICAL WASTE TRACKING FORM <br />White — GENERATOR COPY: Mailed by Destination Facility to Generator <br />Blue — DESTINATION FACILITY COPY: Retained by Destination Facility <br />Green— TRANSPORTER COPY: Retained by Transporter <br />Pink — STERICYCLE COPY <br />Gold — GENERATOR COPY: Retained by Generator <br />16. Transporter 1 (Certification of Receipt of Medical Waste as described in items <br />11,12,&13) �^ <br />Printed/Typed Name Signature <br />. 117. Transporter 2 or Intermediate Handier <br />III <br />(name and address) <br />Ir <br />a <br />N <br />Q EPA or State Med. Waste ID No. <br />Ii <br />I- <br />Date <br />18. Telephone Number <br />19. State Transporter Permit <br />or ID No. <br />20. Transporter 2 or Intermediate Handier (Certificate of Receipt of Medical <br />Waste as described in items 11, 12, & 13) <br />Printed/Typed Name Signature <br />21. New Tracking Form Number (for consolidated or remanifested waste) <br />22. Destination Facility (Certification of Receipt of Medical Waste as described <br />in items 11, 12, & 13) <br />❑ Ppceived in accordance with item�o7l l , 12, & j13 , <br />Z Printed/T ed Name Signature Date <br />O <br />H 23. Discrepancy Box (Any discrepancies should be noted by item number and <br />Z initials) <br />H <br />N <br />W <br />24. Other Information <br />