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• �^ T MEDICAL WASTE TRACKING FORM NUMBER
<br />Q` w®
<br />4Stericycle" FSEF EMERGENCY CONTACT: CHEMTREC 1-800-424* SPANDARD MANIFEST 001 -10 -os -STD
<br />• lrotecenpleopM,RaAudnpRisk:
<br />CUSTOMER NO. 21132
<br />Route #: 133 —
<br />1: Generator's Name, Address and Telephone Number
<br />X10,5 e t%r G RF'a33 „ 'tr
<br />(20a) 12/26/2017
<br />described
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />Bare In
<br />all respects In proper condition for transport according to applicable Intematchat and national govervirgentall
<br />J `Printed/Typed Name AP�tiGl' ix Signature
<br />4. TRANSPORTER 1 ADDRESS:
<br />UlSt:e>riaycle, Inc. This is a Through Skidr
<br />4135 A. awaft: Ave
<br />ac a
<br />Eceano,CA 93722
<br />a Z TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature
<br />S. INTERMEDIATE HANDIER 2 /TRANSPORTER 2 ADDRESS:
<br />N ,
<br />FZ � INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />IE PrinMpe Name Signature
<br />IN 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />I
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Prinb ypo Name Signature
<br />8A. Designated Facility:
<br />MPS. Alternate Facility:
<br />V-
<br />ol
<br />U<.
<br />t
<br />Stericycle, Inc
<br />4136 W
<br />(6r8est3o 427 22
<br />=T22 6 �Q��
<br />St dcycle, Inc.
<br />90 N Foxboro Drfire
<br />North SSR Lake, iii 84054
<br />SA-440-Jh362
<br />TAEAtMSNILITY• i fy that
<br />received ttie a ove i e astes
<br />y ..
<br />CUSTOMER NUMBER
<br />GENERATOR'S REGISTRATION #
<br />Signature
<br />2A. DESCRIPTION OF WASTE
<br />213.
<br />CONTAINER TYPE
<br />2C: NO. OF
<br />20. VOLUME
<br />UN3291 Regulated Medical Waste, mos,
<br />6.2, PGII I
<br />nM — Bio Systens
<br />Wheeled Rack (58.9 CUFT)
<br />CONTAINERS
<br />Cu Ft.
<br />UNS291 Regulated Medical Waste, n.o.s„
<br />6.2, PGI)
<br />KP&3 -° Bio Systems Wheeled Rack (53.5 CUFT)
<br />Cu Ft.
<br />®
<br />6 2, P61) Regulated Medicai Waste, n.o.s.,
<br />,,,.
<br />Ct
<br />Cu Ft.
<br />Q
<br />Regulated Medical Waste, n.o.s.,
<br />„
<br />I® NO g^ `
<br />6UN3P2911I
<br />[.v
<br />, J
<br />Cu Ft.
<br />W
<br />UN3291 Regulated Medical Waste, n.0,s.,
<br />6.2, PGII
<br />Cu Ft.
<br />tZ
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.e.s.,
<br />6.2, PGII
<br />Co Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGiI
<br />RSB _ Bib
<br />stents Cardboard Box (4,3 cu ft)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s ,
<br />6,2, PGII
<br />Cu Ft
<br />3 Generator's Certification: "i hereby declare that the contents of this consignment are fully and accurately
<br />TOTALS 0 -
<br />.�^
<br />described
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />Bare In
<br />all respects In proper condition for transport according to applicable Intematchat and national govervirgentall
<br />J `Printed/Typed Name AP�tiGl' ix Signature
<br />4. TRANSPORTER 1 ADDRESS:
<br />UlSt:e>riaycle, Inc. This is a Through Skidr
<br />4135 A. awaft: Ave
<br />ac a
<br />Eceano,CA 93722
<br />a Z TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature
<br />S. INTERMEDIATE HANDIER 2 /TRANSPORTER 2 ADDRESS:
<br />N ,
<br />FZ � INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />IE PrinMpe Name Signature
<br />IN 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />I
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Prinb ypo Name Signature
<br />Date
<br />Phone#. (866) 783-7422
<br />Applicable Permit Numbers:
<br />Hauler: Reg# 3400
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers.
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers
<br />Date
<br />8C. Alternate Facility: L, f SD. Alternate Facility:
<br />Stericycle, Inc.
<br />1651 Shelton Drive
<br />Hollister. CA 95023
<br />(836)783-7422
<br />TSfOST 83
<br />state agency to accept untreated medical wastes and that I have
<br />Id in that authorization. t
<br />s
<br />„Transferred contalners, eu ft to
<br />0jAN
<br />0
<br />c+
<br />JACQUE WILSON
<br />8A. Designated Facility:
<br />MPS. Alternate Facility:
<br />V-
<br />ol
<br />U<.
<br />t
<br />Stericycle, Inc
<br />4136 W
<br />(6r8est3o 427 22
<br />=T22 6 �Q��
<br />St dcycle, Inc.
<br />90 N Foxboro Drfire
<br />North SSR Lake, iii 84054
<br />SA-440-Jh362
<br />TAEAtMSNILITY• i fy that
<br />received ttie a ove i e astes
<br />y ..
<br />I have been authorized by the appik
<br />In accordance with the requirement c
<br />PrinMpe Name
<br />Signature
<br />Date
<br />Phone#. (866) 783-7422
<br />Applicable Permit Numbers:
<br />Hauler: Reg# 3400
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers.
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers
<br />Date
<br />8C. Alternate Facility: L, f SD. Alternate Facility:
<br />Stericycle, Inc.
<br />1651 Shelton Drive
<br />Hollister. CA 95023
<br />(836)783-7422
<br />TSfOST 83
<br />state agency to accept untreated medical wastes and that I have
<br />Id in that authorization. t
<br />s
<br />„Transferred contalners, eu ft to
<br />0jAN
<br />0
<br />c+
<br />JACQUE WILSON
<br />
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