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Q, <br />cumerr triCCle <br />P <br />r # <br />IcAL WASTE'fiiACK11+IGr FOR <br />INSTAUGTIONS FOR .L . <br />MEDICAL WASTE TRACKING FORM �{f2t�i <br />� <br />z <br />1. iGenerator's a and A� s 2_ Tracking Form N r, <br />� <br />White — TOR Copy: Malied by Destination Faculty to Generator <br />FACILITY COPY: Relained by on Fa�iilPty <br />Bitre — DESTINA <br />Green—. C by Transporter <br />LL- 0 <br />iAdt Memorial P ( <br />� <br />Pink '- ST CYCLE COPY <br />Gold = GENERATOR COPY: Retained by Generator <br />800 SOC 4. State it or ID? <br />3 �15- 24016. <br />Tr porter 1 {Geriificalion of Recelpil of Medical Waste as It:ed it Items <br />5. Transporter's Prfnc e & 6. Telephone Number <br />11, 12,.& 13} <br />A as (2 } 334-34, (g09j 799-8600 <br />Logistics <br />" ---- <br />Ryder Dedicated <br />3600 N.W. 82nd Avenue 7. Transportar Permit lir <br />Printee/Typed e a Date <br />AAiemi,'FL 33168 ID No: <br />EPA or Sfa_ to Died haste ID No. <br />V. Transporter 2 or Iniermedlaie ser TelephoneNumber• <br />UJ <br />(name and address) <br />Fla., <br />i3. Destination Facility Name & Address g. T 3 one flu <br />X903} 799-8.00 <br />~State <br />Transporter Permit. <br />STEFOCYCLE, INC. <br />10390 ENTERPRISE DRIVE 10. S Permit or ID No. <br />�, <br />or ID No. <br />EPA or State Mad: Waste i0 No. <br />Q <br />REDi_AN®S, CA 92374 99-00060-P <br />4 <br />�. <br />M. <br />12. Total No. 13. Total Wfeight <br />t!5 EPA Waste D� Containers or Volume <br />20. Transporter 2 or intemredfate Bendier (Certificate of R pt of Medical <br />13) <br />11. <br />as described In hems 11, 12. & <br />ZWaste <br />!t. Regulated Medlcal.Waste S <br />g. Regulated •cal Waste L <br />Printedff ed blame Stgnalure Date <br />21. Now Tracking Form Number (far consoMated or remanilested waste) <br />C. Speclal Anatomical Waste <br />22. Destination Faclllty, (Certification of Receipt of Medical WaStO as described <br />12, & 13) <br />D. Other <br />in items 11, <br />O ceived In coardance with Item§ 1,.12. & 1 <br />-� 14, special Handling Instructions and Additional k1tormatlon <br />O <br />rinsed a a' a natur <br />Box (An discre ancles should be noted by Item number and <br />23. QlsempanGy y p <br />15. Generator's Cert) etion: <br />Under penaill+ 01 criminal and civic prosecution tar the making or submission <br />1 deciare ort df the <br />4 <br />Q <br />Initials) <br />of false statements, representations, or omissions, :behalf <br />generator <br />that the cflntents of this consignment are futiy and a elan cco�sdanoa with <br />W <br />above and a clri�dkaQ and that 1 have been <br />�` <br />2q, ether tnlormati on <br />Eiji appficabl <br />authorized. in writing, to make such declarations by the-person In ciarge of <br />the genet t s sr 6n. <br />I Z.-/z <br />SI nature Date <br />PrinledlTyped Name g <br />