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-0 MEDICAL WASTE TRACKING FORM NUMB <br />st!Xceri, <br />eIN CASE OF EMERGENCY CONTACT. CHEMTREC 1400-0"300 STAN0 MANIFEST .i., L CUSTOMER NM 21132 <br />1. Generators Name, Address and Telephone. <br />Ito ATTZ: <br />GOLDEK ZXWNG HYPAInk - 569 <br />4545 RBELLEY CT <br />sTOC3=N; CA 95207- 7232 <br />III I911111UiiIIIIYIIINI09pBIBl <br />C"MUIRNusum <br />Transferred <br />SterIcycle. irm. <br />2& DESCRIPTION OF WASTE 20. <br />COWAINERTYPE 2C. NO. OF 20. <br />VOLUME <br />umn,Wed M0111cal Waste, m". <br />am <br />CONTAINERS <br />JUL 0 12015 <br />JUL <br />IT 1,111 <br />- Aff <br />----------- Cu <br />wowRegulatedPeoulalad Meftl Walk no.% <br />Name <br />TS(OST-29 <br />6ZI`G -- <br />- 37 2AL 11W-4-2 SM 1M... <br />Cu Ft <br />Vnep"iMeftl Waste, nom, <br />.21-549 <br />Cu R <br />i"QUN3291 Regulated iNi—cal W-�U%ILCs.. <br />PU <br />TB21- two) 1TLx15- 1path) /TY15- {Ch mo)20 a41 Tub(2.7CUFT) <br />BA <br />Cu Ft <br />U1 U R41111181011 M Wasik ri-M <br />Z 6.21 Poll <br />R21 121-111112 14JAQ110141 <br />Cu FL <br />w <br />W liFUMMedical ante, ".os. <br />W <br />3. Goveriltors CWdl1catI=`I hereby declare that this contents of this consignment are fully and accurately TOTALS ► <br />described above by Ih name, and am desslock pseltaged, marred and labeft&p1scaideA and <br />are In all respects in P=1 Ch "06 for transport accordinip to aWtciible fritsmallonal and national govemmeW91tVlallons? <br />4. <br />Steciewle, Inc. E] TWs is/ rh74h shipment <br />4135 W. Swift Ave <br />Applicable QMtR84,;;7422 <br />Hauler Regilli 3400 <br />Phone #. <br />AWcable Permit Number, <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIRCATION, Reow of medical waste as described above. <br />Pdnvrype Name sipature Data <br />L INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. Phone 0: <br />APPIMWO Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as descmied abova, <br />Name Signature Date <br />cu R to : North Sal <br />ED7 <br />ycle.stairkyCle.11,11C. <br />Transferred <br />SterIcycle. irm. <br />Fodioro Odw <br />1651 stmem oft" <br />M-35W&J409M LAVE <br />Frjtmane NE OR -1`12 <br />so <br />Hollister. CA 2M <br />JUL 0 12015 <br />JUL <br />W-7422 <br />TR <br />race <br />ME FACILITY: I certify that I Have <br />the ab CpPd lunn acro <br />A 11 <br />d2, <br />Name <br />cu R to : North Sal <br />ED7 <br />ycle.stairkyCle.11,11C. <br />SterIcycle. irm. <br />Fodioro Odw <br />1651 stmem oft" <br />3140 H M MetaV <br />Svd Lake. Ur 13404 <br />Hollister. CA 2M <br />Kansas Cky, " as I I s <br />W-7422 <br />(SN)7M7422 <br />(M783-7422 <br />DJA-39 <br />TSIOST83 <br />TS(OST-29 <br />i authorized by the applicable state agency to accept untreated 'medical wastes and that I have <br />:9 with the requirement outlined in that authorization. <br />ORIGINAL <br />rim <br />