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MEDICAL WASTE TRACKING FORM NUMBER
<br /> s ee Stericycle� iN CASE OF EMERGENCY CONTACT: CHEMTREC 1400,424*9300 STANDARD MANIFEST 001 .03.21 •NOCA
<br /> ' CUSTOMER NO. 21132
<br /> 1 . Generator's Name, Address and Telephon t'riW / U 13 " vi i " I-4
<br /> � U1GY � 1 ` - L1t11 'i� � � I11 111
<br /> � 1 i
<br /> n� a '� 2100KAY311 _ � �ATTN : Eric C1*6vilaY � r
<br /> i
<br /> CUSTOMER NUMBER r. rn c Pj e} n r1 I GENERATOR'S REGISTRATION M
<br /> 2A. DESCRIPTION OF WASTE 2131CONTAINER TYPE 20. N04 OF 2D. VOLUME
<br /> i UN3291
<br /> 23291 Regulated Medical Waste, n.o.s„ CONTAIN ! 74 L Cu FL
<br /> UN3291 Regulated Medlcai Waste, n.os., I '1 l t� 101 j _ l r� 1 < t -t1 '•c m J. _ Y 14t- I l ncineral ? 'a
<br /> _ _ r4 =; . . I IID . �t , '- r�, '_Ht J 1
<br /> 6.21 PGI) Cu Ft.
<br /> CC UN3291 , Regulated Medical Waste, n,o.s„ i 1:41 ,,: 1 -1,1_s10 I1 t-"i 3•• I1 SthjI i' 1 'Z-� �: Ii>3rriD3 �' Ltoe . I LID t,: . t t• LIR41
<br /> 0621 PGII Cu Ft.
<br /> Q UN32911 Regulated Medical Waste, n.o.s., 1 1='4 ':1 - ( rj` c; _.____ I 1 61 ' 1'1 U-kl nciri rata J :: t Oat . I L: 7 kc ! la L_ Litt , j
<br /> 6.2, PGII Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n,o.s., tNri' :;-[ •_,IaJ t_ 1t' - tr i ? rri01 Tvv." r • r:, l�rran iJ � _<1 ,a :, . 1LIa , . tLJLlft . j
<br /> Z 6.2, PGII Cu FL
<br /> UN3291 Regulated Medical Waste, n.o.s„ Il~ ox l, f . •aZ , tt ( t , 3
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s., 00
<br /> ��77� �
<br /> 6.2, PGII t fe 1 -Atl . + Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s,,
<br /> 6.2, PGII Cu Ft,
<br /> UN3291 Regulated Medical Waste, r1.o,s.,
<br /> 6.2, Cu Ft.
<br /> 1`011
<br /> 3. Generator's Certification: 1 hereby declare that the contents of this consignment are fully and accurately TOTALS Pop Silos Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br /> are in all respects In proper condition for transport according to applicable International and national governme IyLrepulplon�s."
<br /> Pdnted/Typed Name Date ZZ 22
<br /> OC 4. TRANSPORTER 1 ADDRESS: Phone tf:
<br /> Applicabl6 R@irt IMA ai;r114
<br /> 4 slr3l•icyclo , 111G . �] {"Illi Is 2i 1llt'C7ugh Shipment
<br /> a N 78175 F' A BridgefCrd Rd . TS/OS I"U
<br /> a oc TRANsOroR$ER 'CE IFtt�l1'f ON : Receipt of medical waste as describedAboe.
<br /> ~ PrinUTypeName �v Lei. _�,5 , Signature J�!C'�' i_f✓ urL pate �LJ✓.` 7><—�
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> N
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of med(gal waste as described above,
<br /> PrinUType Name Signature Date
<br /> M 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone X:
<br /> iu Applicable Permit Numbers:
<br /> Q INTERMEDIATE HANDLER ( TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> x
<br /> PrinVType Name Signature Date
<br /> 7, DISCREPANCY INDICATION
<br /> - ~ IIYAN.GA-[ LiSE
<br /> . Designated F*dlATypCLAVEp El 813. kitemats Facility: 8C. Alternate Facility: Ej 80. Alternate Facility:
<br /> 48. tt ilt:y=1C , IniJ1 �/1111 ! IL � Z rttri ) SIL' , Inc . (Incineratofl Ct *;rf,:; cie , Ir,c . fl uorw4l,vej C:ovanta ftnric'oi , Inc
<br /> F 78 6 F, A Hririgeford Rd . Q0 N F=oxboro Orive 2775 E . 2 +3111 St, 4850 DrcjoHaite Road PIE
<br /> Z `;t, nkton , 138208 Mott '; alt Lah lJ `i 84Q546 Vernon , CA 90068 Firno1<•; , OR 73U
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<br /> 'Q T�. -pil NA- IPI _VJA; W FSK f I + t # 3iia
<br /> TREATMENT FACILITY: I certify that I`have been authorized by the applicable state agency to accept untreated m0 cal wastes and that I have
<br /> 1— received the above indicated wastes in accordance with the requirement outlined in that authorization .
<br /> Print/iype Name Signature Date
<br /> ORIGINAL
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