Laserfiche WebLink
MEDICAL WASTETRACWNG FORM NUMBER <br />terlcycte® IN CASE OF EMERGENCY CONTACT: CNP C 1.600.424.9300 STANDARO MANIFEST0DI-WObaTD <br />"�"'"m,,, Ratite #t: 024 - 4 CUSTOMER NO. 211132 <br />1. Generator's Name, Address and Telephone Number <br />GM=N i,MNti RVANA - 569 <br />4595 SM=Y CT <br />ST 11, Ch 95207- 7232 <br />(209) 477-0271 7/22Z2015 <br />CtrMOURNMUR 6080$56-001 GwomaRs Rournumm a <br />2A. DESCRIPTR]N Of wA= 21L CorMINER TYPE 2C. NO. OF 20. VOLUME <br />UNMI ReipMMedUl Wast, a.es CONTAINERS <br />GA Poll T8*5 - 40 Gal Tub [Ria} (5.3 cu ft) C <br />1 3291 z PPoll load Madtsai Wask, n s s„ T810 - 37 Gal 'Tub (Bio) 14.9 cu Lt) <br />® T, PQlI d Meda! Wane, rLe.L. TB14 - 44 Gdl Tub (Aih} (5.9 cu tt) C <br />Q <br />UNS291 Pall ted Medial a o B, x1321- (BXCI) /TP15- IPath)iTY15- (Chem*) gal Tub t2.7CUFT <br />� 6.2, PGIC <br />d .as <br />s2, P131,s. r31-(sio)/friP31-(Path)/tJG31-(Cheata)31 Gal Tub(4.14G } <br />C <br />co 011 MettitalWasle,aas, ws83-(ttia)/21194-(Path)I49-(Chema} 661 Tuh 5.7 } <br />12, R rai tYaste, a s s, <br />2, pall f+ iK1K18 - Viasystems Cardboard sox (4-2 en €t) <br />UNW91. neaumo Medical Wrote, n o 9. <br />3. Generator's Cerllltcadom 9 hereby declare that the contents of ttus consignment are fury and acctuately I TOTALS 00 - <br />described <br />descrRbed above by the proper Bltipplrlg name, and ars dassihed, packaged, mmked and labelled/ and <br />ara In all respects In proper condition for trartspod according to applicable mtemetranal and natcnal gmmrrjvsntd regutallons°- <br />rPr d Noma j-.�8I0MWm, Data/ <br />.TRANSPORTER 4 e N: <br />Stecicycle, Ilia. This is a Tiara h sari (866u mbem* 22 <br />42315 W. Swift ave'� pmteiat Applicable Perrtlt anlbars: <br />Frwano, C& 93722 Battler Reg# 3400 <br />TRANSPO RTIFiCATI :Rete' of asd ~^ <br />P Nmne nature Data 2r <br />S. INTERMEDIATE HANIXIMA 2 /7RANSPOIiTIrR 2 ADDRESS: Phone /: <br />Applicable Permit Number <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medics! waste as described aboae. <br />pdnViype Name Signature, Date <br />e. INTERMEDWE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone A: <br />Apple Pmmot Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of meftw waste as described above <br />PrInVlype Name Slanasrre Date <br />JI IL Z'1201. <br />r FACILITY: I cerhiy <br />a yr <br />1 M. <br />* <br />. ,{ <br />81). Altemata Foctaty. - <br />3 40 it:It Ina. <br />Kansas Cly. KS 66119 <br />TSMT-29 <br />I have 4een authorized by the applicable state agency to accept untreated medical wastes and that I have <br />1 accorlance with the requirement outlined In that authorization. <br />L�7 <br />