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MEDICAL WASTE TRACKING FORM NUMBER
<br />®i ®® tricycle Ro A OFLEMERGEN7 CONTACT: CHEMTREC 1.042 STANDARD MANIFEST 001 -10.06 -STD
<br />CUSTOMER o
<br />MDFROOKTPH
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />T
<br />ANSERIC'ANRED GROSSnSTMKTONl�
<br />65 N C:CM4ERGE ST
<br />STOGKTON, CA 95202— 2318
<br />(209) 644--5031
<br />7/20/20118
<br />CUSTOMER NUMBER 6146762-001 GENERATOR's REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />26. CONTAINERTYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />,Regulated Medical Waste, n.o.s.,
<br />TH04 — 2g Gal. Tub (Bio) (3.7 cu £t)
<br />CONTAINERS
<br />6.2, PGII
<br />6.2, PG
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />TB49 — 37 Gal Tub (Birt) (4. 9 Cu It)
<br />Cu Ft.
<br />X
<br />®
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Bl -- 44 Gal Tub (Bio) (S, 9 au £t)
<br />1 Cu Ft.
<br />UN3291 Regulated Regulated Medical Waste, n.o.s„
<br />TR21— ( ) /TP15— ( ) %TY15— ( ) 20 Cat Tub (2.7CUFT)
<br />Q
<br />6.2, PGII
<br />Cu Ft.
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />W
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n,o.s,,
<br />6.2, PGII
<br />WB43— ( ) /WP43— ( j /WC -43— { } Gal Tub (5.7Cur'Tj
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />6.2, PGII
<br />KR — Bios31stems cardboard Box (4.3 Cu £t)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS
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<br />1 �=/ _ Cu Ft.
<br />Odsg'I above by the proper shipping name, and are classified, packaged, marked and laben carded, and
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<br />in espects In proper condition for transport according to applicable International and nati rnmentat
<br />tet`®
<br />nted/Typed Name Signature
<br />Date
<br />NSPORTER t ADDRESS;Phon$A356)
<br />-7422
<br />U.1
<br />Stecicycle, Inc. ® This is a yh hipment
<br />Applicable Permit Numbers:
<br />4135 W. Swift Ave
<br />H3ulEe Fteg# 340:)
<br />a
<br />Fce*no, CA 93722
<br />ath
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<br />TRANSPORTS ERTIFIC I N: Receipt of medical waste as de 'bed a
<br />~
<br />Prtnt/Type Name Signature
<br />Date V
<br />5. INTERMEDIATE-RANDC-EI4 2 /TRANSPORTER 2 ADDRESS:
<br />Phone N:
<br />Q¢
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />H�
<br />Print/Type Name Signature
<br />Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
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<br />Applicable Permit Numbers:
<br />W
<br />0. 2 z
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printrrype Name Signature
<br />Date
<br />7. DISC EPANCY INDI ATION
<br />y-
<br />DsslgnaW Facility: 883, Attemate Facility: El 8C. Akamate Facility: ❑ 8D. Altarnata Facility:
<br />J
<br />Sterlcyc e, Inc. Sterlcycle, Inc. Sierlcycle, Inc.
<br />Covanta Marion, Inc
<br />v5
<br />9-K 12
<br />41 a5 W. Swift AYS 90 N. Foxboro Delve 1551 Shetton Drive
<br />4850 Brooklake Road NE
<br />LL
<br />Fresno, CA 93722 North Salt Lake, UT 84454 Hollister, GA 95023
<br />Brooks, OR 97305
<br />Z $$(866)783-7422
<br />(801)936-1171 (868)783-7422
<br />(505)393.0890
<br />LU
<br />IGS P-22pAt ANNE 019Ttz 3A 448/!A-3& TSt05T-83
<br />Permit # 364
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<br />TREATMENT FAQTYr,I Aer ' at I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />received the abo I s in accordance with the requirement outlined in that authorization.
<br />11
<br />PrinVrype Name LA d. 44, Signature
<br />Date
<br />T sferred containers, cu ft to :
<br />ORIGINAL
<br />
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