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• MEDICAL WASTE TRACKING FORM NUM13ER <br />Q®; RJt@C1C d IN CASE OF EMERGENCY CONTACT: t 24.9300 srANDARD MAMFEW 061.104*81"D <br />• r �a+ cLfsTaMixR Na 21132 <br />1. Generator's Name, Address and Telephone Number <br />AaTH- I 1111111 <br />IN oil I <br />GGLGLN ,tarVTNG IMAKA — 569 <br />4545 5BEWzy CT <br />sT==V# CA 95207- 3232 <br />_ i�taaai @°�?,�t1'�T4 _ 'a3t9CaN9t�7C <br />CUMMER NUMBER <br />TA. DESCRIPTION OF WA <br />MR Repleled hsillcal Waste. n oa <br />LINMI, Reg � R.o s <br />GENERATOR'S Rent MM R <br />3. Gets Mi aea CarBficatfon: •l hareby declare that the contents ofthis cmisV­ninerri ace fully and accurately TOTALS ► <br />deala�ed above by the prapar slipping name. and are ciassli�d, pecks"d, marked and and <br />are In aM r®specte h! proper r► for transport aocordetg $o appticabie internatwnal end natu>nal g ntaE rtUans." <br />4135 w. swift Ave <br />RI described above. <br />e <br />Tlt"(AT V, _44 <br />IC. NO. OF <br />CONTAINERS <br />73' <br />UR 7422 <br />Hauler Ttieglf 349 <br />Date <br />Phone I. <br />Applicable Permit Numbers. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of mecbral waste as described above <br />PrinVYme Name Slgnature Date <br />S. INTERMEDIATE HANDLER 3 r TRANSPORTER 3 SS: Phone a. <br />Applicable Famtft Numbers. <br />INTERMEDIATE HANDIER /TRANSPORTER CERTIFICATION: Recopt of medcw wage as dewAied above <br />PrinMpe Name signature <br />f,• <br />i. r1!@t9 l .i <br />44 <br />fOST22 <br />JUL 15 "lU 15 <br />TREA ENT FACILITY: I certify that l have <br />f- receive The above Indicated wastes In ac co <br />Name <br />A <br />i'r <br />Aa <br />IRA <br />i Y _ <br />authorized by the <br />i with the requiter <br />—Dale <br />1♦Alternate <br />f FacW. <br />1y ' <br />a3140 <br />KA111115189 coy, KS 66115 <br />:c -7422 <br />Icable state agency to accept untreated medical wastes and that I have <br />outlined in that authorization. <br />Date <br />