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MEDICAL WASTE TRACKING FORM NUMBER
<br /> -0 St MEDICAL
<br /> IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .800-424.9300 STANDARD MANIFEST 001 •03.21•NOCA
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<br /> Route Its: ? 76 _ yi CUSTOMER N0. 21132 1Vls ri4 0001icla
<br /> 1 , Generator's Name, Address and Telephone Number {{ i ll f
<br /> ATTN : I_ t'ic Ci•�:•;,: 1e), � 1 I � � slax lillpt , 1 1 � �� �� � I �il tl � 1 L � t�aT ? 1 ; AY I �II`:1 l ` 1 D/Z�f>+ f.� f !f III I L1 1tit l ill I MILAN if If k � E
<br /> LODI , (.';A95240f%40 ( 2D9 ) 3 ;j9-�' `{ u
<br /> CusoroMER NuMaER 605330M01
<br /> GENERATOR'S RE016TAAVON #
<br /> 2A, DESCRIPTION OF WASTE 2B. CONTAINERTYPE 2C, No, OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., q t , f SCO iNERS
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<br /> UN3291
<br /> 23PGII Regulated Medical Waste, n,o.s., T B2 [ -(Pic 7 T1= 1 := - (Pa i ) _TY '15{ ( Cf't+? mo ) 90 Ga)a TLIO ( 2% 7 CLIP. )
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<br /> UN3291 Regulated Medical Waste, n.o,s., i G- t- (Bio ) TY' 9—i(Cemo Tla0.-( i ` cinerate ) 37 r� aUrL0 es . 0 CLIft6.2, 111311 Cu Ft.
<br /> 621PGl1Regulated Medical Waste, n.o.s., ,r• ,�.t - s?ic� ) __ _. '::\All:: (Cherna ) `;�/i�� ;4plr. l',�ti ) 42 r(3i I . Ifri ( 6 , 71c tl't . )
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<br /> UN3291 Regulated Medical Waste, n.o,s.,
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<br /> UN3291 Regulated Medical Waste, n.o,s.,
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<br /> UN3291 Regulated Medical Waste, n.o,s.,
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<br /> UN3291 Regulated Medical Waste, n.o,s.,
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<br /> 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 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 governmentgragulatiQns°
<br /> Printed/ryped Name Slgnal+l►8 ate 2
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<br /> 4. TRANSPORTER 1 ADDRESS:tnH • 31: r 7114
<br /> W �� tul'IG CI>u , lfic . El
<br /> 'j l ij ;� 1 , a i t11� fi :Shipmium It Applicable Permit Numbers:
<br /> a o go :7175 R A Bridgeliord 1� =.1 .
<br /> N w• tOi. 'sCl in CA 95206)a M`4 TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
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<br /> PrinMpa Name i .--,/ tC re Date
<br /> 6. INTERMEDIATE HANDL 2 / TRANSPORTER 2 ADD ESS: Phone #:
<br /> d 'Rr Applicable Permit Numbers:
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<br /> S
<br /> i INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> ro w 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> w Applicable Permit Numbers:
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<br /> Z INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> � — PrinVType Name Signature Dale
<br /> 7. DISCREPANCY NDiCATION
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<br /> y, i atgnated Facility: 8B. Alternate Facility: 8C. Alternate Facility: 6D. Alternate Facility:
<br /> ..I 9 ~ FENT
<br /> � trricycle , lno . (Indnjarstor) rter,ni n. le , Ino . (Autoclave) C.ivanta ;Y .36on , Ino.1 ElfId1%GA � �t 9 1 H . i=ot:boro Drive :3770a � 51! t�rooldalx goad ! dE
<br /> AN
<br /> cA AVER � rh Sall_W�Ic_• , UT ^�1C15 ' Vernon , (.'A 040051 + �fro!`c, C;ca07'05
<br /> W I m , q r� � ( : 713 f i ' i fd 5617 S1; _ 7122L `( lUGFOR
<br /> NT FACILITY: I certify that I h ve been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> 4ttn W' ales in a cordance with the requirement outlined in chat authorization .
<br /> PrSignature Date
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<br /> ORIGINAL
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