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®a J C MEDICAL%YASTE TRACKING FORM NUN18E <br /> G ep ericyclo IN CASE OF EMERGENCY CONTACT:CHEMTREC 1.800-424-9300 STANDARD MANIFEST 001-10 -5-rD <br /> Route 0: 124 9 CUSTOMER NO.21132 MDFROOMVBM <br /> 1.Generator's Name,Address and Telephone Number <br /> ' <br /> ngica <br /> DTH QUAL LAKE CHAHSPTL <br /> 1221 RG IE LN ' <br /> STOCKTON,CA 95207-6703 <br /> (202)477- VW020 <br /> CUSTOM ErrNUM13ER 81 GENERATOR'SREOl9TRATION <br /> 2A.DESCRIPTION OFWASTE 2e. CONTAINERTYPE 2C. NO.OF 20. VOLUME <br /> 6 232991 Regulated Medical Waste,n.os G�,��1 f } s..# �t CONTAINERS <br /> l / Cri <br /> sZPali Regulated Medical Waste n es 9-37 Gaol Tub )(4,9 QQ Al <br /> CC <br /> 2,MII Regulated Medical Waste,n o.s., 1 CC <br /> —44 Gilt }(5.9 W 2) 4. <br /> Cr: <br /> UN3291,Regulated Medical Waste,n.os., 1„(� 1 1 <br /> a5.2,Pori CU; <br /> LU UN3291 Regulated Medical Waste,rn.o.s., <br /> W 112,1`1311 -1K-X� CL: <br /> 62,G� Regulated Medical Waste.n o.s., 34____— 4 (321 Tub(5.7CUM <br /> CL <br /> 2,PGI Regulated Medical Waste,n.o.s.,6. KR_-Blaroams G (4.3 cu 0) <br /> Cu s. <br /> UN3291,Regulated Medical Waste.n.o.s., <br /> t>2,Pu"tl CU i. <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2,PG11 <br /> of <br /> 3.Generator's Certification;11 hereby declare that the contents of this consignment are fully and accuWaly TOTALS' <br /> descAmst,above try the p r t Cu <br /> oiler shipping rrame,and are classified,packaged,marked and labeiredlplacardrad,and <br /> I specie in prop dation for transport according torl !e International and nagonal overnme r ulatrons." <br /> P [edtrypedMame t ` 'gnalive <br /> NSPORTM 1 ADDRESS: <br /> Swky* Phone#: <br /> p. H , W. This Is to Thmgh Shlpmnt <br /> 4135 W.SWR An Appircable Permit Numbers: <br /> a <br /> 2 F Aa 'CA r1R8 00 <br /> eaFr TRANSPORTER CERTIFICATION;Reeelpt of medical waste as de da e. <br /> X <br /> ~ PdnVType Name Signature Date s <br /> S.INTERMEDrATE HANDL T RANSPORTER 2 ADDRESS: Phone 9: <br /> grB <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpi of medical waste as described above. <br /> PrrnVType Name Signature Date <br /> B.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: phone k: <br /> c rc <br /> Applicable Permit Numbers: <br /> g INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpt of medical waste as described above. <br /> Fz�s <br /> — Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> i <br /> `raA Designated 1=(AUt: Y SEL Alternate Facility eC.A9+emate Facility: (DSD.Alternate Facility: <br /> ng .Inc.µitbodavel � le,Inc.(111chendorl Stericycle,Inc.(Attoclwe) Cwmrft Mwlorl.Inc <br /> 51, 41WW.2VAt AV* 90 N,1 DdW 1551 16on Drl" 4850 SMOMo <br /> Powers.<:AM7`t2 MOM 94ALakr,UT CA Brooke e � <br /> # )7� _ NOII -'• ($IZ! t17! NEs��g�, <br /> 5)393-0820 <br /> Lu -22 SUA-36 TS/OST 83 Permit 364 <br /> )AN 08 2020 <br /> Q TREATMENT FACILITY:1 certify that i have been authorized by the applicable state agency to accept untreated medical wastes and lave <br /> i— received the abgyef�n j�ted wastes In accordance With the requirement outlined Irl that authorization. <br /> G (too ..o <br /> PrrntfType Name Signature Data d3a <br /> CU a to <br /> et III to :N.Sd Laker UT <br /> ORIGINAL <br />