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• MEDICAL WASTETRACKING FORM NUMBER <br />000 Stericydw IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-NO.424.9300 ST MAMFESi' 001-10464M <br />• • rrrtanM.. ft"vo : Route #". 024 — 4 CUSTOMER NO. 21132 <br />T'Fttitli`:fi: fit? <br />i, Generator's Name, Address and Telephone Number <br />ATTN: <br />GOLDEN i,TVINM XOANA - 869 <br />4545 SHE LEY CT <br />S70CMN# CA 952117- 7232 <br />liiiiiiiiiiiiiiiiiiiiIRIIIIIIIIIII <br />Cult= =NUMBER 6D$t}856-001 GawsamFirsRemcmAumIt <br />2A. DESCRIPTION OF WASTE 2a. COMWERTYPE 2C. NO. OF 20. VOLUME <br />U"M� <br />Repalated M n.os., T <br />61 PCdI T805 — 4t) tial Tub tSioi t'.5.3 cra tti <br />dUN399 <br />291d Repsei Medreal Yyaste, n.as„ TB49 — 37 Gal Tub tBi of t4.4 Cu 1ti <br />Cu t1. <br />UN329t Repslated "A'$- <br />62, PGI) TBl4 — 44 Gal TubtBioi t5.9 eu tti Cu R <br />6 it Q°atedt lralwasro,aos T221—tOZO)ITP15—tPat:h)ITYlb—(Chrmv)20 Gal Tub(2.7ctIFT <br />6.2,PGI!---------- -' WWI— (Biel/UP31—(Path)IWC31—Wlsemot31 Gal Tub(G.14cur.7Cu FL <br />UNM Regulated Me6cat waste, n.os <br />12'FMI W843-(Bin)IPIae3-(Patls)1=62—(chemo) Gal Tube-7CWT <br />UN329t Rapialed Medical waste, no.s., <br />6.2, P011 IPM — Bi Wi3rateras Catrdboarct Sox [4.2 cu it! ... <br />3. Generator's CerUgcalion. I hereby declare that the contents of this consignment are hilly and accuaatery TOTALS ► <br />described above by Use proper shWng name, and are classified, packaged, and b besedtplacarded, and <br />are In all respecle In proper condition toy transport accordog to applicable mterrmallonal and national goverrtr entat <br />PrUt Mama w <br />ture <br />4. <br />Stecicyele, Inc. This -is 4 Through 19tipm;ent <br />4335 W. Swift Ave <br />Exeaao,CA 93722 <br />CA : RWWt of MWWI waste as described <br />21 2 ADDRESS: <br />Phone 0- (866)783-7422 <br />Appireffile Permit era: <br />Reales Reg# 3400 <br />Date <br />Phone r <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: necW of modical waste as described above. <br />PdrA%pe Name Data <br />w UT r crw+crirni c MNU err 41 r 14ANSPOKMR 3 ADDRESS - <br />Phone A. <br />Applicable Permit Numbers <br />HANDLER /TRANSPORTER CERTIFICATION: Receipt of madreat waste as described above. <br />Slgnatwo Date <br />--------------- <br />t <br />Stedcycie, Inc. <br />3140 N 7thStre9th <br />Kansas CXCS W <br />S <br />1t M7M7422 <br />IWOST-26 <br />authorized by the applicable state agency to accept untreated medical wastes and that I have <br />i with the requirement outlined In that authorization. <br />. 4 ORIGINAL <br />