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<br /> —— MEDICAL WASTE TRACKING FORM NUMSE.
<br /> tel"icy Ie¢ IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800-424-4300 STANDARD MANIFEST 001-iMG-STC
<br /> R011te #: 124 - 21 CUSTOMER NO.21132 MDa^�ROON09Y
<br /> 1.Generator's Name,Address and Telephone Number i I
<br /> LE- ULDTH QUAL� CHTEASPTIr k f�
<br /> 1221.R08IE L
<br /> STOCKTON,CA 85207-6703
<br /> (288)477-2664 2/12/2020
<br /> cusmmFaNumaER 61 5620M01 GENERAToRSRactsraATrorrtt
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAtNERTYPE 2C. NO.OF 21). YOLUMF
<br /> UN3291,Regulated Medical Waste,n.o.s., CONTAINERS
<br /> s.z,PGu TBO4-28 Gal Tub(665)(3.7 cu t!) c r
<br /> UN3291,Regulated Medical Waste,mos,
<br /> 6.2,PGII TB4$-37 Gab Tub(Rio)(4.8 eta it)
<br /> a: UN3291Regulated Medical Waste,mo.s., -#�Gal Tub(Bio)(5.9 eta 1t) cu
<br /> ® 6.2,PGII Cu.
<br /> 6.23291 Regulated Medical Waste6.2,PGII ,n o s., X21 15 4._)20 Gal Tub(23CUFT)
<br /> 11.11UN3291,Regulated Medical Waste,n.o.s.,
<br /> Z 6.21 PGII
<br /> LU
<br /> UN362,Pall91.Rgulated Medical waste,n.o.s., 3 /1P43 C43 )Gal Tub(5.7CUFT) u_
<br /> 6.23291,Regulated Medical Waste,n.n.s., KR —SiQ ms Cardboard Box 4.3 cu ft u
<br /> 6.2,PGO CuC
<br /> UN3291.Regulated Medical waste,no.s..
<br /> 6.2,PGII C:
<br /> UN3291,Regulated Medical Waste,n.os,
<br /> 6.2,PGII
<br /> Cu
<br /> 3.Generator's Certiflcatiom"I hereby declare that the contents of this consignment are fully and accurately TQTALS
<br /> d9aliLN above by the proper shipping name,and are classified,packaged,marked and labelledtplacarded,and t"
<br /> e in AM Ispects In proper condition for transport according to applicable international and nations vernmentat regulations."
<br /> aved%ped Name CkJA� Signature Q e'
<br /> cc sPORTER 1 ADDRESS: r--� Phone#: 0783-7422
<br /> Ste , Inc. LJ This'l!.- hroUgh Shipman# Applicable Permit Numbers:
<br /> cc 4135 W,rWA t Aare Ha1119er Re 3400
<br /> g N Fresno,CA 93722
<br /> a a Ta ANSPORTER CER FICATION:Receipt of medical waste as desc. a
<br /> Print/Type Name Signalu Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2, Phone 4:
<br /> cc Applicable Permit Numbers:
<br /> $$l INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described abovo.
<br /> PrinItType,Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone+i
<br /> Applicable Permit Numbers:
<br /> UJ
<br /> sINTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described atwve.
<br /> — Printrrype Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> > 8A.Designated Faculty: 88.Alternate Facility: 8C.Af ernate Facility: E]8D.Ahemate Facility.
<br /> .j ricycle.Inc.(Autoclave) Steilcycle,Inc.(incinerator) Sterleycle,Inc.(Autoclave) CevetrTta Marion.Inc
<br /> cs 4 5 W.Sa+vRAve 9Q N.Foxboro Drive
<br /> 1551 Shelton Drive 51850 erooklake Road Iv±r
<br /> Fresno,CA 93722 North Salt Lake,UT 84054 Hollister,CA 95023 Brooks,OR 97305
<br /> LU (866)783-7422 (8mpu'l171 (1366)783-7122 (5015)383-03913
<br /> 'M -22.OMIZ 3A-4481JA•86 TS/OSTe3 a?errnft#8653
<br /> X TRE?"
<br /> FEN IAC I.fiT,Y:I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I ha.e
<br /> t- received the above firs fcated wastes in accordance with the requirement outlined in that authorization.
<br /> Prrnt/Type NArrtg'a !1 Signature Date
<br /> Transferred mtalners, cu 0 to :Brooks,OR
<br /> Transferred containers, cu b to :N.Salt lake,UT
<br /> — r�lxlrtnlat_ —R— —
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