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• MEDICAL WASTE TRACKING FORM HUMBER <br />Os ®® Stericycl IN CASE OF EMERGENCY CONTACT: CHEMTREC 1400424 -MOD MAf4FESTw1-10•o6s'rc <br />• ►'MI' I RDute #: 024 — Q CUSTOMER NO. 21132 DFROQUIU6 <br />Generator's Name, Address and Telephone Number <br />ATTR <br />GOLow LmNG ImAwn - 569 <br />4545 SMLEY CT <br />STOCKT011, CA §5207- 7232 <br />pI�I�111NIIIII11111111UNll <br />477-0271 <br />1 <br />3. Gerterstoes Certification: 7 hereby declare that the contents of this consignment are fully and ac cumf* TOTALS 10- <br />described <br />i►described above by the proper name and are etesaik d, packaged. necked and labellediplacan:14— wnd <br />are In all respects to prt>per oda lar tam accombrig to applicable uternallonat and goys cars" <br />'PdntecIffypedName I tili nabtre <br />LTRANSPORTER 7 ADDRESS. <br />Steeicycl ® Inc.. This is a Through paean <br />4335 D. sift Ave <br />nar CA 9 722 <br />TRANS FIC N otmedical waste as des MW abeve <br />2 <br />O <br />Date <br />Phone N• 4866? 783-1422 <br />Applicable Pemrti Numbers <br />Emlec 3400 <br />Rata <br />Phone N: <br />Applicable Permit Numbats <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: RacMpt of inedical waste as described above. <br />PdnvTwa Name Signature Date <br />S. INTERMEDIATE HANDLER 3I TRANSPORTER 3 ADDRESS: Phone N: <br />Applicable Permit Numbers. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of Medical waste as descnbed above <br />PrfnIffype Name Signature Date <br />CunoutinNumaim 6080&56-001 <br />GEui_RffQW2REQWRA=NN <br />2A, onscRiFnoN OF WASTE <br />2e• CONrAINERTYPE 2C. NO. OF ZD. VOLUME <br />UN3291 Regulated Medical Waste, "s, <br />61 Pali <br />CONTAINERS , <br />S — 40 Gal Tub (Riot (5.3 cu %tt Cu Ft. <br />62, pGd Regulated Medical Waste, Ru.s <br />TB49 — 37 Gal Tub (8i®t (4.9 Cu tCt Cu Ft <br />CC <br />s2,P�tlli tadMedicolWasN,nos, <br />TB14 — A4 Gall Tub(T3iat (S.9 cu tit v cu Pt <br />I�RebatedMedical Waste.nos, <br />T=L—(Patb)/TYlS—(Chemo)2Q Gal Tubt2.7C <br />cult <br />5.2. PGIi Reguhted M®dICN Wase, R o a, <br />1— tole) /WP31- (PatW/WC31- (Chemor) 31 bat Tub (4 ,14C Ft <br />IZ <br />6a,PGd <br />3- Bio 184[43 -(Path /C143 -(ch I Gal Tub(S_7CUPT) <br />UN329t R�ulaled Waste, n os , <br />6.2, Poli <br />— Vi ems Cardboatd Box (4.2 cat tit c„ <br />1 <br />3. Gerterstoes Certification: 7 hereby declare that the contents of this consignment are fully and ac cumf* TOTALS 10- <br />described <br />i►described above by the proper name and are etesaik d, packaged. necked and labellediplacan:14— wnd <br />are In all respects to prt>per oda lar tam accombrig to applicable uternallonat and goys cars" <br />'PdntecIffypedName I tili nabtre <br />LTRANSPORTER 7 ADDRESS. <br />Steeicycl ® Inc.. This is a Through paean <br />4335 D. sift Ave <br />nar CA 9 722 <br />TRANS FIC N otmedical waste as des MW abeve <br />2 <br />O <br />Date <br />Phone N• 4866? 783-1422 <br />Applicable Pemrti Numbers <br />Emlec 3400 <br />Rata <br />Phone N: <br />Applicable Permit Numbats <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: RacMpt of inedical waste as described above. <br />PdnvTwa Name Signature Date <br />S. INTERMEDIATE HANDLER 3I TRANSPORTER 3 ADDRESS: Phone N: <br />Applicable Permit Numbers. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of Medical waste as descnbed above <br />PrfnIffype Name Signature Date <br />lE,NfT Fac LIITY.,I3ce�U�j%tF1at I have <br />the above Indicated wastes In acro <br />e <br />Name ' a/71 -X. <br />01 <br />T <br />i� <br />r� <br />SO. Attenute Fecky. <br />SterlcytWe, Inc. <br />3140 N 7/.th,�Sdt9bthv <br />Kenm (dye K9 09115 <br />(8651783-7422 <br />TMST -26 <br />authorized by the applicable state agency to accept untreated medical wastes and that t have <br />i with the requirement outlined in that authorization. <br />Date <br />4 <br />lE,NfT Fac LIITY.,I3ce�U�j%tF1at I have <br />the above Indicated wastes In acro <br />e <br />Name ' a/71 -X. <br />01 <br />T <br />i� <br />r� <br />SO. Attenute Fecky. <br />SterlcytWe, Inc. <br />3140 N 7/.th,�Sdt9bthv <br />Kenm (dye K9 09115 <br />(8651783-7422 <br />TMST -26 <br />authorized by the applicable state agency to accept untreated medical wastes and that t have <br />i with the requirement outlined in that authorization. <br />Date <br />