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<br />It : 134 - 9 CUSTOMER NO.
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001 -10 -06 -STD
<br />1. Generator's Name, Address and Telephone Number
<br />TTN:Lavonne Baldwin I
<br />APUMCAIN RED CROSS-STOMMIN
<br />65 1 CCMKM= ST
<br />STOCWMV, CA 95202-- 2318
<br />209 644--5031
<br />7/25/2018
<br />CUSTOMER NUMBER _001 GENERATOR'S REGISTRATION N
<br />2A. DESCRIPTION OF WASTE 2B• CONTAINERTYPE
<br />2C. NO. OF
<br />21D. VOLUME
<br />UN3291 Regulated Medical Waste, mos.,CONTAINERS
<br />6.2, PGII
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<br />6.2, PGII
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<br />UN3291 Regulated Medica Wasie, n.o,s.,
<br />6.2, PGI
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTI-
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, an
<br />are In all respects in proper condition for trans rt according to applicable International and national governme I rula ti ns"
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<br />Printed/Typed Name ve Signature
<br />4. TRANSPORTER 1 ADDRESS:
<br />Date
<br />Phor>A_1i '
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<br />Steciay�clet IRC. his is a Thcough.shi,pwe
<br />6� 70, 7422
<br />Appll ab a PX umbers.
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<br />4135 11. swift Ave
<br />ulac Reg# 3400
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<br />Irreano,CA 93722
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<br />TRANSPORT ION: Receipt of medical waste as de
<br />Print type Name a ` I v Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone M: ;
<br />Applicable Permit Numbers:
<br />oui
<br />a�
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone If:
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<br />Applicable Permit Numbers:
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<br />N I a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />FPrtnVType
<br />Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />¢
<br />BD, Alternate Facility:
<br />8A. Designated Facility: 69. Altemate Facility: E] 6C. Attemat® Facility:
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<br />. kIG. , iflC, W , ilx.
<br />, Inc
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<br />36 W.o N' ! 004
<br />48M BrooWds Road NE
<br />F uT H011111111111K. CA SM
<br />SaLske30
<br />Brooks, OR BT305
<br />z $
<br />1 1171bn
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<br />TREATMENT FAC1L1�a'tf,�,t�_grtify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the abov scat wastes in accordance with the requirement outlined in that authorization.
<br />tom-
<br />Print/Type Name Signature
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<br />Thmofmw Owdainmi out to
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