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n <br />@i'IC�G�@' — — Rd CASE OF EMERGENCY CONTACn 1400424,9300 <br />i r"0 <br />ft"I"hftow Route At: 123 - 6 CUSTOMERNO.21`132 <br />MEDICAL. WASTETRACIONG FORM NUMBER <br />STANDARD M,wtF2sr oomo ae aro <br />tt :) i 4 I 1 fl :. <br />1. QeneratoPs Name, Address and Telephone Number 11111 <br />ATT)t: Sharon Miller <br />IN II��� <br />�p eSTCC=''N <br />-CLI <br />EXTA <br />2350 <br />STOMTOW, to 96204- 6606 <br />SQA) 943-0864 <br />12/19/2017 <br />Custom Nuasen 6018098-002 GENERATOWS RBGWFRArIONi <br />2A. DESCRIPTION OF WASTE 20. CONTTYPE <br />2C, NO.OF 2D. VOLUME <br />'"` rr <br />61 o�l(ReAuiot®Q Medical n OA, T - 40 Gal Tuba His u ft) <br />CONTAI <br />�'la Cu FL <br />pP�81 Regulated bete, ns. <br />.o, <br />&2,PSIf TH49 - 37 U2t1 Tub '(Rio) 9.9 Ou 'Ct) <br />CU a- <br />m <br />SU PSI) Regulated Meftal Waft, 0.0-% TBl4 - 44 Gal Tub 8i 5.9 Cit tt <br />t-- <br />UNW Regulated fie, <br />6A poli T132i- (talo) /TP15- (Bath) /Tx1S- (Chemo) 20 Gal Tub (2.7CDF'T) <br />&Z PGli RM 31- (R,io) /WP31- Bath /WC31- Chemo 31 Gal Tub (4.14CM) <br />CUB. <br />LLL <br />BN$ cif Mdket Waxa' n.aa. <br />Cu ft <br />Regulated Medical Watt6.2%, nos., . <br />m1) Repute! VM�ta, n o e„ <br />Cu Ft <br />UW Bf Regulated tr , n,o a, <br />Cu Ft <br />3.Oenerator'a CoMflostion: 9 hereby declare that the =*mts of lege Mu4mmIt are fuay and ata5tTA� f► <br />Cu Ft <br />tl above tn� qm p name, and are n:d, marked and ca <br />are M In for tranq:ort ( to ap Intemakonal and na gu <br />�' 22 <br />Nates Yt' �3d/ tura <br />Dai <br />4. TRANSPORTER 1 ADDRE . <br />Phoma "'(866) 783-7422 <br />Stericycle, Inc. This is a Through sh pmaut <br />AppgbableFormaettunbers <br />4135 W. Swift ABO <br />Hauler Req# 3400 <br />Fre O'CA 93722 <br />a. <br />TRANSPORTER C CATION: Receipt of medical waste as ds=ftd <br />y <br />Print/tjtpeNmra tJ , <br />fttl 1 <br />S. MIRVAEDiATE HANDL 2/TRANSPORTER 2 ADDRESS- <br />Phone e' <br />n <br />ApoWable Permit Numbem <br />INTERMEDIATE HANDLER /TRANSPORTER CATION: Receipt of ineftal wasta as deacdbed above. <br />PdnV ype Name <br />Data <br />A <br />e. INTERMEDIATE 3 /TRANSPORTER 3 ADORM <br />Pion d. <br />a Perms Numbers <br />1. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: oi medmad as abs <br />PQww Nettle <br />Date <br />7. DISCREPANCY INDICArION <br />f <br />Wd Fadaty: 0 Sa. ARmosto Pavy: W Fader <br />So. AKWUMO FacBr. <br />j <br />.156 5'te AW ' pity® <br />am camuft maim ine,S,clet7 <br />e+anara«e <br />30 N, tO&A® tai <br />22 s4�( <br />� <br />DEC <br />( rad- <br />212017 <br />Tolosm <br />DEC 1917 <br />a <br />TREATMENT FACIi.n'Y: t cerlthIl i have been aulhodzed by the applicable state agency to accept untreated ave <br />recdIved the about es Irl accordance w Ith the requirement outttned in that authalzaton. <br />Prk*TYPG Nemo <br />Date <br />Trmbrrod IL conUdItum, zu A to <br />