Laserfiche WebLink
. Pustallmer plumber, r7%{ <br />Handling Inslruclions and Additlonat Irrtorlaaltan <br />15. Generator's Cerilllcatlan: <br />Under penalty of s, repr and civil prosecution for the making or submission <br />of !else statements. representalions, or omissions. I declare on behalf of the <br />generate! <br />that the rsontents of This conal <br />above and a cl s�i'� gnrnent are lull) and accurately described <br />ala pplicable �� a ! Waric d p ed to accordance with <br />aothorizecf, in writing, to �}� ,j and that i have been <br />I he ge ra is operation. <br />declarations by the person in charge of <br />r <br />'ntedrTvnari Nam* <br />Cin aturq DBl9 <br />+...rte <br />I-WHIG11116 AS t• CO.4PLETIAG <br />Destination MGenerator <br />Blue DESTINATION . by Destination <br />Green— TRANSPORTER COPY: . , by Transporter <br />Pink — STERICYCLE COPY <br />Gold — GENERATOR COPY: <br />16. Transporter 1 • (Certilleation of Peceipt of Medical Waste as described In items <br />.11, 12,&13) <br />t=117. Transporter 2 or Intermedliste H <br />H (name and address) <br />0 <br />CL <br />Q EPA or Sial® Mod. Waste, iD <br />2Q Transporter 2 or intermediete tiarntler (Certificate <br />Waste as descnbed in Items i I ° 12, &13) <br />. k - <br />R t <br />t� <br />21. New Tracking Farm Number (tor consolidated or remeniiested waste) <br />27- De stination Facility (Certification of Receipt of Medical Waste as c <br />In items 11, 12, & 13) <br />Ci Received in accordance with items 11. 1 & 13 <br />Priniedrryped, am <br />rr` 23. Discrepancy Box (Any <br />Z initials) <br />th <br />W ' <br />24. Other information <br />should be noted by item number and <br />11, <br />----------- <br />G <br />G <br />m <br />�G <br />m <br />MEDICAL WASTE TRACKINP FORM <br />1.Oan$retar°s i�me and <br />... Adds <br />�. <br />� <br />2 Trrecking Form Number <br />Lodi Mftww ti op I<SNF, <br />LL- -00-6994- <br />8t% 8©lith Lower$mhtelito <br />3• x93240 <br />4. State P�rinii or ID t • " <br />S' T orter's Princlple <br />-Address (�U9) X4,3412 UWihg <br />G J one Number <br />pYder Dedicated Logistics <br />" 3WO N.W. 82nd Avenue <br />(909) 799-8500 <br />. <br />. FL 33166 <br />7. myter Perrrjt or <br />EPA of State Allod %,baste if) Na. <br />fD No- <br />' <br />. Destination FacIlityName & Address <br />9. Telephone Nu <br />INC. <br />(909) 799-8500' <br />:.t[ aICYCL� <br />EiVT1=RPRfSE DRIVE <br />REDLANDS, CA 92374 <br />10. Swo Permit or to No. <br />99-O 60-P <br />11. US EPA Waste Ijqelcrlptlon12. Total Me. 13. Total Weight <br />A. R Containers or volumedated Medical Waste g <br />B. Regulated Medical West. <br />L <br />C- SPOCial Anatamicaf Waste <br />D. Ofiter <br />Handling Inslruclions and Additlonat Irrtorlaaltan <br />15. Generator's Cerilllcatlan: <br />Under penalty of s, repr and civil prosecution for the making or submission <br />of !else statements. representalions, or omissions. I declare on behalf of the <br />generate! <br />that the rsontents of This conal <br />above and a cl s�i'� gnrnent are lull) and accurately described <br />ala pplicable �� a ! Waric d p ed to accordance with <br />aothorizecf, in writing, to �}� ,j and that i have been <br />I he ge ra is operation. <br />declarations by the person in charge of <br />r <br />'ntedrTvnari Nam* <br />Cin aturq DBl9 <br />+...rte <br />I-WHIG11116 AS t• CO.4PLETIAG <br />Destination MGenerator <br />Blue DESTINATION . by Destination <br />Green— TRANSPORTER COPY: . , by Transporter <br />Pink — STERICYCLE COPY <br />Gold — GENERATOR COPY: <br />16. Transporter 1 • (Certilleation of Peceipt of Medical Waste as described In items <br />.11, 12,&13) <br />t=117. Transporter 2 or Intermedliste H <br />H (name and address) <br />0 <br />CL <br />Q EPA or Sial® Mod. Waste, iD <br />2Q Transporter 2 or intermediete tiarntler (Certificate <br />Waste as descnbed in Items i I ° 12, &13) <br />. k - <br />R t <br />t� <br />21. New Tracking Farm Number (tor consolidated or remeniiested waste) <br />27- De stination Facility (Certification of Receipt of Medical Waste as c <br />In items 11, 12, & 13) <br />Ci Received in accordance with items 11. 1 & 13 <br />Priniedrryped, am <br />rr` 23. Discrepancy Box (Any <br />Z initials) <br />th <br />W ' <br />24. Other information <br />should be noted by item number and <br />11, <br />----------- <br />G <br />G <br />m <br />�G <br />m <br />