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i10 <br />i� t@i1C�►C! IM CASE of Y COQ'[ n CHEMTRE,C 144 424.93W <br />h+mr.'+. :: — 9 CUSTOMER NO. 21132 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />1. Generator's Name, Address and Telephone Number i <br />ATTN: !f 11 It <br />GOWIEK LrVYNG HWANK - 569 <br />4545 SEE=y CT <br />STOCKTONO CA 95207- 7232 <br />(209' 477-0271 6!1712015 <br />enNnasem 80856-001 GewruxroarsRF.s imurnouli <br />2A. DESCRIPTION OF WASTt 2131, COKAINERTYPE 2C, NO. OF 20 VOLUME <br />ffillit Regulated Medkal Waste, n a s.. - 40 Gal (Sioy (5.3 cu ft) CONTAINERS <br />62, illi Cu Ft. <br />VP___, Rooftd NPR waste, %o s. TB49 - 37 Gal Tub (NO -S' 4.9 CU -?U--- <br />® 6t 1� flegutaed M meal Waste, nee., TBL4 - 44 Gal Tub ( 41 (S. S eat ft) <br />F <br />� ti2, tW R M Medkar WMte.. a.o s., - a - <br />uF <br />W Ae Medlpf Waste, pp,s,, 1- (13ia)E cJP?1- teathj wCu- tc�etaa) 6 <br />W <br />62, PGI <br />tJAognlatedMe CUF <br />Gmi3-(Bi.o)JPW3-teatb)/CW:I-(Chemo) sax Tub(5.7CEWT) <br />cF <br />NWIj FMgWM iWiG'1W3sK ra®.s., mo - Biosystms Cardboard sax (4.2 cu ft) <br />ffP t Reg Dialed MedlW Waste, US., <br />Ca F <br />X2 CUP <br />3. Genaratoes Certification: •I hereby declare that the contents of -this consignmeritare I* and accurately F <br />described above4y this proper shipping name, and are cless8ed, p , marked and Kett ed, and <br />are In allrespaNs to proper corddlan for transport according to applicable Intemational and national Gomm"regutaitkoW <br />t <br />ilPrintacYroad Name - M A410 -Q—. m 4 i <br />1011M: This �3 a TltL ! PtlOrie tU• `a vu, r v�� r s ___-- <br />SCaricycle, Inc. <br />4135 V. Swift: Ave Applicable Eau�etrN 3400 <br />Freatto,CaA 93722 <br />FIC •Rax of m waste as described above <br />Ssgaalare Dude <br />(-/7-/f <br />)L&2 /TRANSPORTER 2 ADDRESS, Phase � <br />Applicable Permit NUmbem- <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recotpt or medical waste as described above. <br />PdnV ype Mom signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone / <br />Appinxble Permit Numbers, <br />pdwrAw Nim <br />Slgnatum <br />Date <br />7. DISCREPANCY WD <br />Tmsbmd C611i hms, <br />ou R 10 _ Haft Sak Lake, UT <br />I 8A. Designated Facility: <br />ria. Alternate Faelllty: <br />aC Aftirmals FadhW. 8D. Alto�mrate Faetitty: <br />e7W , Iiia. <br />e� <br />Inc. <br />mt$49 VV <br />E <br />SO (d. )r <br />16/1 t�Itee' ® <br />3'1140 N }�, <br />t"°i <br />WA0FRTIZ <br />North ,UT <br />Holllsbr,CA 3 <br />C:IM.IGS MIIS <br />(SM76XY422 <br />(8M783-7422 <br />(OW763-7422 <br />2 <br />36 <br />83 <br />-26 <br />JUN 1Tzm- <br />rR f FACILITY: I Certify thdt I <br />a teed a vis In cared vstaatc s to <br />N <br />been authorized by the applicable state agency to accept untreated medical <br />dance wdh the requirement outlined In that authorizagon <br />wastes and that I have <br />' ® a <br />Signature <br />Oats <br />