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- -- — — — MEDICAL WASTE TRACKING FORM NUMBER <br />®�"a* S' rACjj e- IN CASE CF EMERGAENCY CONTACT. CMEMTREC t-fN RD oot.taoaSTP <br />„ ,,�, ,o, Route #: 123 - 6 CUSTOMER NO. 21132 MDFR00JYUJ <br />1. Generator's Name, T9.Sa and Telephone Number <br />A't'R'N: 6Sharon Mailer <br />�t4c-RAY-�a. ra►rzE -s <br />2350 N CALTXCRtNIA ST <br />S , cA 95204- 5506 <br />(209) 943-0654 1215/2017 <br />60'18098-002 GINERco" RGONFRATM 6 <br />2A. DESCRIPTION OFWASTE 21L CONTAINERTYPE 2C. NO. OF 20. FUME <br />aa.t poll Fte9UfatE1 Waste LQJa THDS — 4Q trial Tub {Bio) (S.3 cu ft) CONbAR�RS Cu Ft. <br />RIMPILReoWated Meftal Waste. ass.. TB49 - 37 Gaal Tub (Bio) (4.9 CU it) Gee Ft <br />® tt2 heli R09UWW Mgftl Waft P.G.L. TSl4 - 44 Gaal Tub (Bio) (5.9 cu tt) CURL <br />4 ?=III <br />P III MKW WaaK, a.as„ T - BIO TP - Pa Ty - ema Bea T CtmT Cu R. <br />W ®t11 2. PQMod—kW-W.—..- 1-(Bio)/MP31-(Path)/KC31-(Chemo)31 Gal Tub(4.14CUPT <br />ti Qu Ft <br />ROW" Waft aos., 43-(Bio)/RW43-(Path)/CK63-(Chemo) Gaal Tub(5.7CUPT) Ou R. <br />6 2. Pali Re9tftW Med W Yaffe, ass., OW - Biosystema Cardboard Box (4.2 cu tt) Cu Ft. <br />Phone t:: (866) 763-7421 <br />ShipmemAppecable Psmd Numbers. <br />nauler Reo 3400 <br />> <br />Phone s: <br />Apphcable P®tmit Numbers: <br />EDIATE HANDLER /TRANSPORTER CERTIFICATION: Reow of waste as de$cMed above. <br />Name SOMUN10 Date <br />w 6. INTSRMED1ffE HANDIM 3 /TRANSPORTER 3 ADDRESS: Phone #. <br />Applicable Pemr& Nmbonc <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Reoso of aseftal waste as <br />Pd WWG Name Date <br />62. wl "°y...,�, "�,.........a ".rte, %ol <br />_ <br />i, <br />S. GietwratoPa . y b&vW declare that the contents of this oansIpment are hdY aq <br />br ft aro maksd and <br />� <br />8 it to <br />boml and nateP <br />"Men" OR= <br />AM: <br />`. <br />ped NatneT'ff,7ato <br />rr OS x <br />DEC 05 2011 <br />RIADDREEf�g <br />Stericyrsle, Yno. <br />[] This is a <br />4x35 W. Swift Ave <br />t, <br />Frerano,CA 93722 <br />4• <br />Phone t:: (866) 763-7421 <br />ShipmemAppecable Psmd Numbers. <br />nauler Reo 3400 <br />> <br />Phone s: <br />Apphcable P®tmit Numbers: <br />EDIATE HANDLER /TRANSPORTER CERTIFICATION: Reow of waste as de$cMed above. <br />Name SOMUN10 Date <br />w 6. INTSRMED1ffE HANDIM 3 /TRANSPORTER 3 ADDRESS: Phone #. <br />Applicable Pemr& Nmbonc <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Reoso of aseftal waste as <br />Pd WWG Name Date <br />U ac AftenWe Fecift U w. <br />ii= DGive <br />CA 85023 <br />(]8:i-7422 <br />TS/OST 83 <br />IcaNe state ages%= to wept untreated m Wastes and that I have <br />outlined in that euthotizallon. <br />Date <br />r* <br />i, <br />W' <br />90 <br />"Men" OR= <br />North Sattaft, Ur KM <br />`. <br />rr OS x <br />DEC 05 2011 <br />.r <br />4• <br />U ac AftenWe Fecift U w. <br />ii= DGive <br />CA 85023 <br />(]8:i-7422 <br />TS/OST 83 <br />IcaNe state ages%= to wept untreated m Wastes and that I have <br />outlined in that euthotizallon. <br />Date <br />