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<br />MEDICALWASTETRACKING FORM NUMBER
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1400-42"300 STANDARD MAANFEST OM-10-WSTO
<br />Route #: 184 - 7 CUSTOMER NO. 21132 MDFROOGGIG
<br />1. venerators Name, AOcsresS and Telephone Number
<br />ATTH
<br />GOLDEN SKIVING RYP - 569
<br />4545 SIMLWY CT
<br />s ox, CA 95207-- 7232
<br />�I I I I 111 Igloo I I 1110111111
<br />(209) 477-0271
<br />5/13/2015
<br />3. Generatoes Cartiticatiert; •t hereby declare that the contents of this consignment are fully and accurately I TOTALS ► ,y j
<br />described above by thepmpsr ah Ramey and are classified, packaged, marked and la teed, and
<br />are In a0 respools in proper condi for tranelort according to a Wernatbnal and natlonai governmental regulakons,
<br />Arl 01,1110 -6• (Pnntedllyped Mama vM°�-abtra, Dela $
<br />4. TRANSPORTER 1 ADDRESS Phone 8- Erg
<br />SteriCyale, Inc. ❑ TUB is a Through shipment
<br />Applicable Permit Numbers:
<br />4335 W. Swift Ave Hauler: R,egt# 3400
<br />rresno,CA 93722
<br />TRANSPORTERCERTIFICATION: Receptor rnedfcal waste as desciftied above.
<br />2 /TRANSPORTER 2
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of meftell waste as described abmirs.
<br />Print/lype Nears Signature
<br />I, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />INTERMEDIATE HANDLER /'TRANSPORTER CERTIFICATION: Receipt or mackel waste as described above
<br />a
<br />Nemo
<br />T. DISCRE°ANG
<br />Phone f•
<br />Applicable Permit Numbers.
<br />Date
<br />Phone If.
<br />Appkable Permit Numbers.
<br />Signature Date
<br />Transterred ., wNorth
<br />CusTommNueraen 600856-001 GENERAMMSREMSTRATtON0
<br />2A. DESCRIPTION OF WASTE 26. CONTAINER TYPE 2C. NCL OF
<br />2D,
<br />Regulated Meftl Waste, a a s, CONTAINERS
<br />MESHTi305 - 40 Gal Tub (Bio) (5.3 d:1$ ft)
<br />V
<br />ij
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<br />$.2 Poli Regulated MedIW Waste,n.as, 7849 - 37 Gal Tub MiO (4.9 Cbl tt)
<br />CC
<br />8 2 PGIi Regulated Wcal Waste, a o a iT014 - 44 Gal Tub (Elia) (5.9 au tt)
<br />13 201
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<br />Oi�i2, �i Regulated Med&af Waste, n.o s., x823- (SIP) !4'p1S- t 2'atfi) jTY35- (Chrmo 20 Gal Tub t2 • C }
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<br />l APGIi NWI Regulate Waste. n o s , W831- (Bto) /WP31- (Path) /KC31- (Chemcr) 31 Dal Tub t 4.190 )
<br />6A2, P6
<br />mi
<br />f'1A poli Irlated Medtwb e, nos„ 16843- (Bio) ®PW13- (Patch) /CW43- Memo) Dal Tub (5.7CUFT)
<br />M Sri Medical Waste, n.m m, Kn — Bi.Ossrstesas cardboard Sox (4.2 Cot 1 t)
<br />3. Generatoes Cartiticatiert; •t hereby declare that the contents of this consignment are fully and accurately I TOTALS ► ,y j
<br />described above by thepmpsr ah Ramey and are classified, packaged, marked and la teed, and
<br />are In a0 respools in proper condi for tranelort according to a Wernatbnal and natlonai governmental regulakons,
<br />Arl 01,1110 -6• (Pnntedllyped Mama vM°�-abtra, Dela $
<br />4. TRANSPORTER 1 ADDRESS Phone 8- Erg
<br />SteriCyale, Inc. ❑ TUB is a Through shipment
<br />Applicable Permit Numbers:
<br />4335 W. Swift Ave Hauler: R,egt# 3400
<br />rresno,CA 93722
<br />TRANSPORTERCERTIFICATION: Receptor rnedfcal waste as desciftied above.
<br />2 /TRANSPORTER 2
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of meftell waste as described abmirs.
<br />Print/lype Nears Signature
<br />I, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />INTERMEDIATE HANDLER /'TRANSPORTER CERTIFICATION: Receipt or mackel waste as described above
<br />a
<br />Nemo
<br />T. DISCRE°ANG
<br />Phone f•
<br />Applicable Permit Numbers.
<br />Date
<br />Phone If.
<br />Appkable Permit Numbers.
<br />Signature Date
<br />Transterred ., wNorth
<br />SM Alternate Fadgly:
<br />Sterigde. ink.
<br />--90 N. FoXbOM Drive
<br />North Salt Lake. UT- 04M -
<br />authorized by the
<br />a with the requireir
<br />* Stgrmture ___,
<br />❑ 8C. Aftomate Faditty AD, Ax—m a FaCMW.064
<br />tcable state agency to accept untreated medical wastes and that I have
<br />outkned In that authorization.
<br />Sbedoycle, SIC. Sterlcyc[e, Inc.
<br />1651 Shelton Drive 3140 N 7th Streettriji
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<br />SM Alternate Fadgly:
<br />Sterigde. ink.
<br />--90 N. FoXbOM Drive
<br />North Salt Lake. UT- 04M -
<br />authorized by the
<br />a with the requireir
<br />* Stgrmture ___,
<br />❑ 8C. Aftomate Faditty AD, Ax—m a FaCMW.064
<br />tcable state agency to accept untreated medical wastes and that I have
<br />outkned In that authorization.
<br />Sbedoycle, SIC. Sterlcyc[e, Inc.
<br />1651 Shelton Drive 3140 N 7th Streettriji
<br />H@@oi3�tyer. CA 96M iCa�QQrt�sy\a.p,e��,jC���ippty'.//g�K,��3 86115
<br />scg6�q 1�8T�e(y4iaf: tv.ra°lj yWSTgIL+4I51L
<br />14'7PVa71 ®J 1-
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