Laserfiche WebLink
w <br />TT <br />.- <br />77 <br />2 <br />16: <br />®® 5#erlcyeie• <br />MEDICAL WASTE TRACIaNQ FORM NUMBER <br />IN CASE OF EMERGENCY CONTACT: CHEMtTREc 1.800.4249306 SVMMM MANIFEST0111•11e.me STO <br />Route #: 184 - 7 . CUSTOMERN0.91132 MDFROOG8 <br />Generator's Name, Address and Telephone Number <br />ATTN: <br />GOLDEN LIVING 117PATA - 569 <br />4545 SBELLEY CT <br />STOCKTONg CA 95207- 1232 <br />(209) 477-0271 3/18/2015 <br />DUSMMERNUMBER 6080856-001 SWERAioRSREetBinATlontt <br />2A. DESCRIPTION OF WASTE 25- CONTAINERTYPE 2C. NO. OF 20. VOLUME <br />UN3291 RepulalMl Medigl 0 0 5 , CONTAINERS <br />02.P61E THOS — 40 Gal Tub (SW (5.3 Ca E'c) Cu <br />Eh - <br />r ISE Cu <br />MedkW Waft ass., T89 9 — 37 Gal. Tub (Hies 1 (4.9 cu. tt) <br />Ce FL <br />Poli elated Waste; n os„ 44 Gal Tub (bio} (s. 4 cu. ity _ <br />UNMIJ IAPeated Mom Wast Ihm 31— 4Sio) /WP31— (Path).TI C31-4Chemo) 31 Gal Tub (4.140 ) <br />8.2, PBI <br />Cu <br />s°2, P6iE Re9uiated Medlraf Wase, a.o s , t d:k- 41iti.o) /ee43- (Path) /Cra43— (Chemo) Gal Tub (5.7CWFT) <br />Cu <br />lj) lbquMW , n.e.s, MLBL_ — Biosystems Cardboard Box (4.2 cu tt) <br />3. Generators CerNtleatton, "I hereby declare that the contwft of ibis consignment are fully and accuratelyTOTALS E► <br />described abuva the properIno name, and are dassilled, packaged, marked and and <br />are In all respect 1 M proper con for transport aaeordlpg to applicable uriematbnal and natbnal governmental regulaboW <br />Nfry% A ..1 — I <br />( <br />6 <br />1 TV1 <br />1 S:""we N. la — <br />Stericycle, Inc. 0 Tbia is a Throughshipment <br />4136 W. Swift Ave App Permit Nm <br />Eresno,CA 93722 8au3et Reg# 340Q <br />Phone R: d <br />Applicable Permit N umbew <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recept of medical waste as described above. <br />Prlrift a Name 819nature Date <br />IL INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS <br />Phone li. <br />Applicable Permit Nursers: <br />HANDLER /TRANSPORTER CERTIFICATION' Receipt 01 medical waste as described abon. <br />Signshere VMS <br />IcInnvr 4MW-n..vry <br />Transfimid contalners, at ft to : North Soft Lake, UT <br />isterated Fa Ulty: sa.Alt�rreto Fsanity: ®aC Altemam Fecelty <br />cycle, Inc. Stericyrule, Wo, <br />413 Y61E 90 N. Feftm Orin 1551 Shelton Oda <br />(e RTIZ North So 7422 Lake. UrHaNater. GA <br />(866}703-7422 <br />9A AAs. kA 9r �ee.c+ae..s.t <br />8 2015 <br />ATMFAGI • I cartily that I <br />'wed t l�vAnd1caW stes In <br />l <br />3D.Ahernsm FaclIty: <br />Ster1cycle.Inc. <br />3140 N 71h *tttty <br />Kawas City. KS 66115 <br />(866)783.7422 <br />TWOST-26 <br />been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />dance with the requirement outlined In that autlWzabon. <br />Date <br />