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3. Generator's Certification: `I hereby declare that the contents of this amognment are fully and accurately I TOTALS ® <br />Cu Fl. <br />MEDICAL WASTE TRACKING FORM NUMBER <br />*® Stericycle° <br />• <br />IN CASE OF EMERGENCY CONTACT. CHEMTREC 4 -NO 42 STANDARD MANWEST 001 -10 -MM <br />• <br />a °°�'a ® • <br />Route #; 024 — 4 CUSTOMER NO. 21132 KDFR00GA01 <br />[.-t Slgnatttre <br />iPdrtt Name <br />1. Generator's Name, Address and Telephone Number <br />A.TRANSPORTER 1 ADDRESS. <br />SteriaWle, lao. This is a Through e)ripmaent <br />Pima a: (866) 783-7422 <br />Appli able Permit Numbers: <br />o <br />a. <br />EN ZIV:rM H2PANA <br />- 669 <br />a <br />4546 SBELIXY CP <br />(!( <br />STOCHM11, CA 95207- 7232 <br />Date <br />(209) 477-0271 4/1/2015 <br />phone a <br />CusroerMNUMBER 6080856-001 G sREorsTnaTaoaa <br />2A. DESCRIPTION OFWASTE <br />2e• <br />CONTAINERTYPE 20. NO. OF 20. VOLUIM <br />UN3291 RepulatedMedical waste, a.os., <br />8.2, PR <br />Date <br />CDNTAHttats <br />TWS - 40 Gaal Tub (Biu) (5.3 au ft) Cu F <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS <br />6.2 FOli Regulated Mattai Waste, n os„ <br />TB49 - 37 Gal Tub (13ioli (4.9 cu -ft) Cu <br />CC <br />Rl 4t Repubted Waste, ri o s , <br />T1317.4 - 44 Gal Tub talo) (S.9 cu %t) gg FL <br />Q <br />8329%1 Regulated Medial Waste, no s. <br />T921- (si®) /TP15•- tPathl /TY19- (Chemo) 20 Gal Tub (2.7Cum) <br />a <br />Cu Ft. <br />W <br />W <br />11N3291 Regulated f�diCat Waste, P-0-9. <br />8.2 R, <br />A. Ignaled FaWtty: <br />UB31-48ia)/WFP31-4Path)/WC31-(Chetaa)31 Gal Tub(4.14C <br />aD. Atton+am Facnny: <br />p2.Pcti <br />Sbft%Tje. Inc. <br />rr1843-(Sia}1Pot33-{Perla?/eAraA3-{a)aemo) Gal. Tub(5.7CUPT) <br />Sterlayde. Inc. <br />UN3211 Regutaud Medical Waste, n o L. <br />6A PH <br />Ave <br />=8 - Biosystems Cardboard Box (4 2 cu it} Cu Ft <br />3140 N 7th Streettry <br />gt � Regulatsd Medical Waste, P.O.L. <br />r"47) <br />fir% -�- '2C -4A . ''lam C " 7 t .... <br />3. Generator's Certification: `I hereby declare that the contents of this amognment are fully and accurately I TOTALS ® <br />Cu Fl. <br />described above by die proper shWintl imine, and ane classified, packaged. marked and labelledUlacarded, and <br />are In all respects In condition for accorag to <br />proper 'tmnspod applecabta entemsMwna! and national govem mentet regotwns' <br />XI7t <br />V • <br />r <br />[.-t Slgnatttre <br />iPdrtt Name <br />Data — s <br />f rs/ <br />A.TRANSPORTER 1 ADDRESS. <br />SteriaWle, lao. This is a Through e)ripmaent <br />Pima a: (866) 783-7422 <br />Appli able Permit Numbers: <br />o <br />a. <br />At35 W. Swift Ave <br />FCestto,C A 93722 <br />Ftaulec Regi 3400 <br />a <br />TRANSPORTER FICA N: R=RA dwal waste as described above. <br />(!( <br />PnnVtype Nomis Signature <br />Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />phone a <br />N <br />Applicable Permit Numbers <br />SO <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Rempt of medical waste as downbed above <br />PrinViype Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS <br />Phre N: <br />Applicable Permit rAftera: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Remipl of medical waste as dumbed above <br />Name Signature <br />Date <br />7.OISCRERANOY INDICATION <br />3 <br />may® <br />/() p� g }y <br />q �y �s,,,M Laker <br />t.�tl r® ZO . NOl6� l7aN l.tiiScr V e <br />A. Ignaled FaWtty: <br />Prismata Facnity aC. Alternate Faalay: <br />aD. Atton+am Facnny: <br />Sbft%Tje. Inc. <br />Slafla cle, Inc. Sterloide. Inc. <br />Sterlayde. Inc. <br />Ave <br />80 N. F060M Drive 1551 Sitobn 0" <br />3140 N 7th Streettry <br />Fresno. CLAVE <br />�� <br />` Sat LAe, LIT Be4DS-DS- 1 oS , A S D23 <br />M7422 (866)783-7422(86tiy7t3'-28 <br />Kansas .KS; "tis <br />-7422 <br />ANNE ORTIZ <br />t -JA-36 83 <br />-26 <br />w_} <br />T fMENT FAQ 11 I 6 <br />ved the above Indicated was <br />iqe by the applicable state agency to accept untreated medical wastes and that I have <br />r Ia utrement outlined to that authorization. <br />P J CQ <br />E WIj S N <br />srgnre <br />Date <br />2015 <br />Lll28 <br />ORIGINAL <br />