Laserfiche WebLink
MEDICAL WASTE TRACKING FORM NUMBER <br />�,• Stericycle'IN Cj�1SgEQF J COOENCY NTACT CHEMTREC 1.800.4249306 STANDARDMANIFEST001-10•oe.I TE1 <br />• ►•ieaAyanW4 tat ROtlte A� CUSTOMER NO. 21132 MDFROOJVQQ <br />ORIGINAL <br />1. Generator's Name, Address and Telephone Number <br />ATTN:Sharon Miller <br />FMC -RAI -N. CALIFORNIA STOCRTON <br />9911 Ilia"I'MMT 5506 <br />(204) 543-4854 <br />11/7/3017 <br />6018098-002 <br />Cummr-riNuusEn GENEUTOIrsREGISrRATION$ <br />2A. DESCRIPTION OF WASTE 213. CONTAINERTYPE <br />2C. NO. OF 20. VOLUME <br />N3291Regulated Medical Waite, THOS - 40 Gal Tub (Bio) (3.3 Cu tt) <br />CONTAINERS <br />62, 291i <br />Do Ft <br />o) (4.9 Cu t <br />3GA �I Regulated Medica] Waste, rms„ al 49 - 7 GTub t) <br />Cu Ff <br />a <br />UN321� Regulated Medical Waste, n.o.s., T814 - 44 Gal 'Pub (Bio) (5.9 Cu 'Et) <br />Cu Ft. <br />OQ <br />Regulated Medical Waste, no a, T - RI ITP15- Pa TY -(Chemo)20Ga Tub ( . 7CUFT <br />UN3291 <br />ON <br />Cu Ft. <br />WB <br />2911 Regulated Medial Waste. 10-%- W931-(Bio)/WP31-(Path)/WC31-(Chemo)31 Gal Tub(4.14CUFT) <br />Cu Ft <br />fit <br />62DPG111R�gulatedMedicalwaste,noS„ WR42-(Rio)/PWd2-(Path)/CWd2-(Chemo) Gal Tub(S-7CuPT) <br />Cu Ft. <br />Bif Regulated Medical Waste, no s„ t�8 - Biosystems Cardboard Box (4.2 cu ft) <br />Cu Ft. <br />P61i Regulated Medial Waste, n.o s. <br />d <br />82, <br />Cu Ft <br />UNP01I Regulated Medical Waste, n.os, 1 _ <br />Ire <br />3. Generator's Cardficalon: 9 hereby decla that the contents o this consignment are fully and accurately TOTALS ) <br />Cu y, <br />dep d above by the proper shipping name, and are classified, packaged, marked and labelle ed, <br />actor ng to a b1e imern fional and nation mmreg <br />�.�daspectsinpropercondiitransport <br />1 11 P ntedi% ed NameLe <br />4.T SPORTIER 1 ADDRESS: r-� <br />Stetieycle, Inc. �1ei s is a Through Shipment <br />47 <br />L /10) f <br />Phone If.(8b 83-7 2 <br />1 <br />4135 A. Swift Ave t'— <br />Applicable Permit Numbers <br />Haulet Reg# 3400 <br />o. <br />FCesno,CA 93?22 <br />N <br />o°c Z <br />TRANSPOR E FIC N: Race[ t of medical waste as <br />PrkfVtype Name Signature <br />Data <br />B. INTERMEDIATE HAND 2 SPO 2 ADDRESS <br />Phone N: <br />Applicable Permit Numbers, <br />INTERMEDIATE HANDLER !TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />PrIntrType Name Signature <br />Date <br />;, <br />8. INTERMEDIATE HANDLER 3 /TRANSPORTER S ADDRESS <br />Phone R: <br />Ls¢i g i <br />tc <br />a <br />Applicable Permit Numbers. <br />y 3 <br />INTERMETNATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />3 <br />Primer yps NEW Signature <br />Date <br />7. DISCREPANCY INDICATION <br />r <br />aA.Dedgn dF dW. ae. Alternate t=idily: ❑ M Aftemete FacUft-. <br />D99D. Aftemate Faelnty: <br />r, <br />t-Or{ve <br />' �aa'riE rr° f a <br />41135 Wl�EOfflU SOSW <br />185=ottDrive, <br />"0 araa"� s <br />a`ti. 1 <br />1 <br />3 <br />Fresno Cdr 93722 North SA Latw. Ur 84054 Httltis6r3r, CA 95Q23 <br />=,18&7422 <br />(556)7 722 VMS- <br />7 2017 VMS- 736 TWOsr 83 <br />NOV LUt <br />:99 I <br />TREATMENT FA& rtffy that i have been authorized by the applicable state agency to accept untreated medical wastes a <br />recen+ed the above Indicated wastes in accordance with the requirement outlined In that authorization. <br />Pdntrlype Name Signisum, IDate <br />Con[alifl•y�.• �, 4 CUM! <br />C <br />ORIGINAL <br />