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MEDICAL.WASTE IrRACKING FORM NU&913
<br /> ®®! tericycid Wl CASE OFVEM IG NCY CO�iTACT CHEMTREC I-800-424-9310 STANDARD MANIFEST 001-10-05-STD
<br /> t{OUCH 5 CUSTOMER NO.21132 MDFROOM' 010
<br /> 1.generator's Name,Address and Telephone Number
<br /> ATTIC',2sephine Yokingco
<br /> DTH QUAL L XE-OHATEAU HSPTL
<br /> 1221 ROSEMARIE LN
<br /> STOCKTO N,CA 95207-6703
<br /> (209)477-2664 12123/2019
<br /> i .
<br /> CUMAWR Numem 6156205-001 GENERATorrs Rt atSTIMMO a#
<br /> I 2A.DESCRIPT1ONOFWASTE 2B, CONTAINERTYPE 2C.NO.OF 20. VOLUME
<br /> CONTAINERS
<br /> s 2,PG1[ Regulated Medical Waste,D.O.s., TBO4_28 Gal Tub(t31o)(3.7 cu ft)
<br /> C�
<br /> 6 2M1.Regulated Medical Waste,n.o.s., T849-37 Gast Tub (Bio)(4.9 to ft)
<br /> p UN321 Regulated Medical Waste,rLo-s ;4 44 Gal Tub(Bio) (5.9 cu ft) a:
<br /> & UN2,341 Regulated tve&al Waste,no.s.. •( aW
<br /> cc
<br /> Cu
<br /> LU UN3291,Regulated Medical Waste,n.o.s.,
<br /> z 6.2,PGII Co .
<br /> UN3291 Regulated Medical Waste,n.o,s.,
<br /> 6.2,PGII .WB43-(---JME43-(_--J/WC43-(___-__)Gal Tub(5.7CUFT)
<br /> Cu
<br /> 62 PGII Regulated FAedtcaE Waste,n.o.s, KR -BliosWilents Cardboard Box(4.3 cu ft)
<br /> 11143291,Regulated Medical Waste,n.o.s.,
<br /> i 6,2,PGII ,
<br /> UN3291,Regulated Medlcai Waste,n.o.s.,
<br /> 6.2,PGII
<br /> 3.Generator's Certffication:"9 hereby declare that the contents of this consignment are fully and accurately TOTALS® Cu
<br /> desc bed above by the proper shipping Dame,and are classified,packaged marked and labetied/ carded,and --
<br /> n respects in proper condition for transport according to If utterna0onal and naft ovemmemai regulations"
<br /> rinted/ryped Name Sign r Date �-
<br /> a.T sPORTTs;R 1 Sten eyrie, Inc. [ This 18 a Thrott h Shi Ment Phone#: -
<br /> A tleabte Permit Numbers:
<br /> r 4135 W.Shift AVe P Hauler Re 3400
<br /> Qo, Hauler 93722
<br /> c�
<br /> qiz TRANSPORTER CERTIFICATION:Receipt of medical waste as describ bo
<br /> Print/Type Name Signature Data
<br /> S.INTERMEDIATE HAMEh 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> Applicable Permit Numbers:
<br /> zs INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recent or medical waste as described above.
<br /> i J`- Print/Type Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone A;
<br /> w 5 W Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> ILI
<br /> Print%pe Name Signature Date
<br /> T.DISCREPANCY INDICATION
<br /> y- 8A.Designated Facility 88.Alternate Facility; 8C.Alternate Facirity: Q 8D.Alternate Facility:
<br /> :3 Ste cycle,Inc.(Autoolave) Stsrlcycte,Inc.(Incinerstor) Stericycte,Inc.(Autoclave) Covants Marion,Inc
<br /> Z3 1 4135 W.SvuifEAve 80 N,FoXboro Drivst 1551 Shalt)on Drive 4850 Brooklake Road NE
<br /> Prerorru,�Md 72'g Moot SoltL.uk4.UT 641164 Hollat+er,CA S5023 Brooks,OR 97305
<br /> 'L 11 (105)1^tS3-74 (81191936-117 9 (8156)783-7422 (5135)393-t3$9t3
<br /> z TS/OST 22 3A-448/JA-36
<br /> uJ # Ts/aST-sa Perrr�ft :a5d
<br /> LU TREATME ity that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> 1— received th t astes In accordance With the requirement outlined In that authorization.
<br /> Print/Lype Name Signature Dale
<br /> vurfrart J%31N, UU It to 8FOOkS,
<br /> OK—
<br /> Transferred containers, ou ft to :N-Salt Lake, UT
<br /> ORIGINAL
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