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• MEDICAL WASTETRACKtNG FORM NUM13ER ` <br />® p Stericycl@' IN CASE OF EMERGENCY CONTACT: CHEMTREC t STANDARD 001-1048-M"««ma" a Route tis 123 - 6 CUSTOMER NO.21132 MDFR00JZT7 <br />1. Generators Name, Address and Telephone Number <br />I <br />ATTN:Sharon Miller <br />235Q�-C1RMCMEEA SST <br />$, CA 95204- 5506 <br />1111111111111111111011011 <br />(209) 943-08b4 12/12/2017 <br />2. Generator's CoMeation: 9 hereby declare that the oontenm of on c»risittnmam are br and accurately I TOTALS <br />10- <br />describW atm by are proper sWppbv musa. and ars daWK psckag4 mats ed and and <br />are In aA respects M r =ddon for Itimsport L ai am! <br />. ,�, � w <br />dm <br />CUSITOWERNUMMM 60'19098-002 GEasxroWs Rso,arnnamma <br />Fh" 4* 2 <br />2A. DESCRIPTIONOFWASTE 29. CO RTYPE <br />Inc. ® This is a Through Shi mt <br />®i Ro WEA a os, fico - 44 Bal fiuh (Hie) eu tt? <br />UNMIli Mihai Walla las TB4 - 37 Gal Tub (Hio) (4.9 ou t:t) <br />ILP <br />Hauler 3400 <br />ti.2. PMi ft*WWa'ts' --3- TD14 - 44 Gal. fine (Bio) (5.9 cu TQ <br />Fre9no,CA 93?22 <br />62,P61iR a0s� ¢H2t-tezallcr2s-tp®ct,?/rxts-(cha o}2a Gal rubt2.7cs r1 <br />a <br />n Pall R" s o s" WWI- (910) /WP31- (Path) I 31- (C11e010 31 Gal Tub t4.14CUPT <br />BRIzFF011 ate" !t8@3 -two)/ 1-tFat1!}/CIt43-(Chmta} sial Tub(5.7CMIT) <br />n. INTERMEDIATE RANDLER 21 TRANSPORTER 2 ADDRESS: <br />"'1N3891 ' Me4cai Wase n toa <br />tL2. ptatl >iRB- HiosYste� Cardboard Box (4.2 cu ft) <br />2. Generator's CoMeation: 9 hereby declare that the oontenm of on c»risittnmam are br and accurately I TOTALS <br />10- <br />describW atm by are proper sWppbv musa. and ars daWK psckag4 mats ed and and <br />are In aA respects M r =ddon for Itimsport L ai am! <br />. ,�, � w <br />dm <br />ADDRESS' <br />LT PQRTER 1Stericycle, <br />Fh" 4* 2 <br />Inc. ® This is a Through Shi mt <br />Applicable <br />4135 W. Swift Ave <br />Hauler 3400 <br />Fre9no,CA 93?22 <br />a <br />TRANSPORT ERTIFIGATION: Reoe4A of medical VAWO as d <br />n. INTERMEDIATE RANDLER 21 TRANSPORTER 2 ADDRESS: <br />Data <br />Phone a: <br />Appheable Permit <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of modest wasm as described above. <br />pftgype Name swnsturs <br />Date <br />'a <br />a. INTOWMX 4TE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phoma e: <br />Parma Numbers: <br />INTERMEDIATE /TRANSPORTER CERTIFICATION: Receipt of market as above <br />ftWfto Nwno_— <br />Dam <br />T. DISCREPANCY I <br />Fusty: as Aftermse Factithr. <br />0 SIX Alternate F <br />35 tW N.4 07 • Ma.O 1056, kx. <br />' LR SWWe <br />83-736 <br />TV= 83 <br />TREq AAENT FA t i hall bean audu,rized by tits a state a= accept untreated medlcal and that I have <br />receRred the above wastes 6t with the requirement ouUln� in that a dzat&on. <br />PAWI�" Name Swank- <br />Date <br />ORIGNAL <br />