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T MEDICAL WASTE TRACKING FORM N1UPAE
<br /> �®®� 'fieri' cle® iN CASE OF EMERGENCY CONTACT:CHE6tTREC I-BOD-424-9300 STANDARD MANIFEST 001-10.06-STO
<br /> Rowe #: 124 - 7 CUSTOMER NO.21132 MDFR00M014
<br /> 1.Generator's Name,Address and Telephone Number
<br /> DTH QUAIL LADE CHATEAU
<br /> ne Yokielgco
<br /> HSExTl.
<br /> j 1221 ROSEWE LN
<br /> STOCKTON,CAI: 03207-8703
<br /> 200)477-2864
<br /> i Ctrs mEnNuMaL=R 6156205-001 GmEmTomsREGtwRATlONIt
<br /> ' 2A.DESCRIPTMN OF WASTE 2B- CONTAINER TYPE 2Q NO.OF 2D_ VOLUME
<br /> UN3291 Regulated Msdicai Waste,n.a.s., CONTAINERS
<br /> 6.2,PGIi TRU-28 Gal Tui E" 3.71Ct1!t C.,
<br /> s 2,PPGtli R=gulated#tedicat Waste,n.o.s., 7 Gal TUb( )(4.9 cu ft)
<br /> O
<br /> 6.2PLfNG11 Ry9uiated Me6Ecai t"laste,n.as., 4— Gaal Tub S� 6.2 cu A)
<br /> Q UN3291,Regulated medical Waste,nosWaste.
<br /> 11: 62,FGil 14_..-X18-�fTY18- �}2t1 t3>;EtTt# (2. 'GlfF7)
<br /> li! UN3291,Regulated Medical Waste,n.o.s.,
<br /> Z 62,PGI!
<br /> UN3291 Regulated Medical Waste,n.a.s.,
<br /> 6.2,PGIi /VW43 ' Cal T .7CU c,
<br /> i 62,PGII Regulated Med(cai Waste,n.o.s., KR_w UiorMe x Car4ktwd Box 14.3 cu ft
<br /> 6232p'31 Regtdated medical Waste,n.o.s.,
<br /> ' 62,PGI!Regulated medical Waste,n.os.,
<br /> 3.Generator's Certification:`I hereby declare that the contents of this consignment are fully and accurately TOTALS
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and
<br /> are In all respects in proper condlll for transport according to applicable international and national govern regutati s" i
<br /> Printedfryped Name Sfgntaturo Date
<br /> 4.TRANSPORTER t ADDRESS: Phone 4: (seepro ¢22
<br /> j �_jnC IL1. .T i4 is a T1 rou 1plinent Applicable Permit Numbers: ;)
<br /> o 2 �, Hamar Reg#3400
<br /> IR
<br /> 4 TRANSPZ) ZFICC tof decal ste as descn t
<br /> PrinUTypa N Slgnat
<br /> S.INTERMEDIATE HANDLER 2ITRANSPORTER 2 ADDRESS: Phone tr:
<br /> � x Applicable Permit Numbers:
<br /> swig
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described abcve.
<br /> PrinitType Name Signature Date
<br /> cam, 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> Applicable Permit Numbers:
<br /> a a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Z
<br /> — Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> SA. Ignatsst Faculty: 88.Alternate Facility: 0 8C.Alternate Facility: Q 8D.Alternate Facility:
<br /> " cycle,Inc.(Autoclairve) SEericycie,Inc.(Incinerator) Stsrieycle,Inc.(Autocia+Ie) Covantee Marion,Inc
<br /> a - 4136 W,5vvlft Aire 90 N.Foxboro DtNte 1661 Shehrt DM 4550 BrooWske Load NE
<br /> IL Fresno,CA 93722 North Sat Lake,CIT 84054 Hollister,CA 85023 Brooks,OR 97305
<br /> u &li83783-7$1 ($Oi} 36-#t71 (86S)793-7412 fsSOM93-0990
<br /> It TISIOS r-22 3A-448MA-36 Permt*364
<br /> DALE ANNE QFYItZ
<br /> f &I TREATMENT FACILITY:I certify that 1 have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> i i' r received[vl� bNn"*d Wastes in accordance with the requirement outlined in that authorization.
<br /> t 14 PrInt/rype Name / 3 Signature Date
<br /> f da
<br /> Trainsbirred containers, cu 8 to:8raoks,OR
<br /> 7rainsterred cmalners, Cu ft to _N.!Sok Lake,UT
<br />
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