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`+9 ��C�Y���A
<br />- - — ^ - — — MEDICAL WASTE TRACKING FORM NUMBER
<br />ROUt:L P.jTERGE1! f CONTACT: CHEMTREC 1.800-424-934 STANDARD MANIFEST 001 -10.08 -STD
<br />CUSTOMER NO. CONTACT.
<br />®F' RQOKT9B
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN: Lavonne Baldwin
<br />AMERICATI RETS CROSS-STOCITQN
<br />li� �1�IiiM1 1 �1 l
<br />i p I I��I���til t<� �Ri11�ilE Iii ���
<br />65 N COMIE2CE ST
<br />CONTAINERS
<br />16$ .PGIi
<br />STOC=ToN, GA 95202-
<br />2318
<br />Cu Ft.
<br />UN3291, Regulated Modical Was10, n.o,s.,
<br />B49 - 31 Gal Tub (Bio) (4.9 cu tt)
<br />(209) 644-503.
<br />7/18/2018
<br />ntrsrnu;:nNtluaFn 6146762-001
<br />GENERATOR'S REGISTRATiDN #
<br />2A. DESCRIPTION OFWASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291Rog ulated Medical Waste, rl.o.s.,
<br />B04 --26 Gal Tub (Bio) (3.7 cu ft)
<br />CONTAINERS
<br />16$ .PGIi
<br />Cu Ft.
<br />UN3291, Regulated Modical Was10, n.o,s.,
<br />B49 - 31 Gal Tub (Bio) (4.9 cu tt)
<br />6.2, PGI I
<br />Cu Ft.
<br />t1N3291 Regolated Medical Waste, n,o,s,,
<br />DB14 - 44 Gal Tub (Bio) (5.9 CU ft)
<br />.2, PGIi
<br />Cu Ft. I
<br />N3291 Regulated Medical Waste, n.o.s.,
<br />— —
<br />.2, PG ii
<br />Cu Ft
<br />N3291 Regulated Medical Waste, n.o s.,
<br />21 PGIi
<br />Cu Ft.
<br />J13291 Regulated Medical Waste, [I.o.s.,
<br />/WB42- ( } /Wcu- ( ) Gal Tub (5.7CQBT)
<br />1,21 PGIi
<br />Cu Ft
<br />N3291 Regulated Medical Waste, 11.0,s.,
<br />tR Biosystems Cardboard Box (4.3 cu ft)
<br />6.2, PGIi
<br />---
<br />Cu Ft
<br />43291 Regulated Medical Waste, 11.0 s,
<br />2, PGIi
<br />Cu Ft I
<br />Regulated Medical Waste, n.os.,
<br />23PGIi
<br />j A
<br />t/
<br />Cu Ft
<br />i. Gonerator's Gertlticatlon: "t hereby declare that the contents of this consignment are fully and accurately
<br />T®YACs ®
<br />Cu Ft
<br />wl FudU UUUYtr Uy trio pi".' .....w, -. u v -u .... ' N.nw.0 1. ' ...u...0 ........ .............. r.�......i ......, ......
<br />in all respects In prop6r condition for transport according to applicable International and national governmental regulations"
<br />TPIANSPQRT RaiiA1Gya xI.1C. U This is a Through Shipment
<br />4135 A. Swift Ave
<br />rrezino,CA 93122
<br />IANSPORTSR CERTIFICATION: Receipt of medical waste as described above.
<br />r
<br />Int/Type Name �(� Signature
<br />INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
<br />EDIATE HANDLER /TRANSPORTER CERTIFICATION.' Receipt of medical waste as described above.
<br />Name Signature
<br />HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />TERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />ht(Tvae Name Signature
<br />Des{ignated Facility:
<br />iycla, Inc.
<br />W. SWItAve
<br />U 8B. Alternate Facility:
<br />erlcycle, Inc.
<br />0 N. Foxboro Ddo
<br />U 8C. Alternate Facility:
<br />Stericycte, Inc.
<br />1551 Shelton Drive
<br />La CA 93722
<br />703-7422
<br />18T-22
<br />lorih Salt Lake, UT 84054
<br />1 8t7 1)936-1 t 71
<br />A,.448/JA,,36
<br />Hollister, CA 85023
<br />()783-7422
<br />Tsi4ST-83
<br />Applicable Permit Numbers:
<br />Hauler Reg# 3400
<br />-�-rsr-14e
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Data
<br />i-[ 8D. Alternate F20[Tty:
<br />Covanta Marlon. Inc
<br />4850 Brooklake Road NE
<br />Brooks, OR 57305
<br />(605)393-0850
<br />Permit # 364
<br />[ENT FACILITY: i certify that i have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br />the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Name _lignature Date
<br />
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