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MEDICAL WASTE TRACKING FORM NUMBER
<br /> �i e� Stericycle• IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .8116.424.9300 STANDARD MANIFEST00I , o3.21•NOCA
<br /> ' Psi OUIe It,: % Or. - 21 CUSTOMER No, 21132 PJIDT0110 } I--II3
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> Al"►N : Eric Cr41'A IT/ t
<br /> TC r ,aY E1f1� l.Y :; i '=;_ C1 ! �� z
<br /> 312 S HAIR }' 0161! T OVE y -1 �1a?2022
<br /> IMI , CA 9i2AO- 3040 ( 2:051) 3G9
<br /> -5 -I1 u
<br /> 6053? OMO I
<br /> CUSTOMER NUMBER GENERATOR'S RSOISTRATION N
<br /> 2A. DESCRIPTION OF WASTE 28, CONTAINER TYPE 2C. NO, OF 2D. VOLUME
<br /> 623PGIIRegulated Medical Waste, riots., it?;)_ rtltl � TYVJ ,,- ( Inciner :rte ) 41 Gal , TL[bI Niltltl
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, T � '1 - (1 IC j _ _ Tf "159 •-(Petit ) _ T Y 'I6401ali9o )• 2C Gtal . TUb (2 7 ('. +-IT'i . )
<br /> Cu Ft.
<br /> C 612t UN3291 , Regulated Medical Waste, n.os., r ; I _^ _ 1~: i0 TYa G'- Chernc i 1 /104 l r Cin�' r?iC' � T t �I . hl ; d , =t � +. ft • '
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<br /> UN3291 Regulated Medical Waste, n.o.s., �,r;r2 � ' -( �iG )•_ � 41r, 3 (+,' flalila )_�J`,�{43 -( F' h = :Tr; ) '� � Ci al , lu _ ( 5 .7C:ult . )
<br /> IM 6,2, PGI} Cu Ft.
<br /> W 6 23P9GiI Regulated Medical Waste, riots„ { 1 F._ _ (1 io ) r; al , Coldrug ax.ted Bo (,�? 432 Cults )
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<br /> (.5 UN3291 Regulated Medical Waste, riots.,
<br /> 6.2, PGII � Kwpuvciooj A . I . Cu Ft,
<br /> UN3291 Regulated Medical Waste, n ,o.s •, so
<br /> 6.21 PGII 0, its Cu Ft,
<br /> UN3291 Regulated Medical Waste, n,o,s„
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s. ,
<br /> 6.2, PGII Cu Ft.
<br /> 3, Generator's Certification : "I hereby declare that the contents of this consignment are fully and accurately TOTALS / 7. d Cu Fta
<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 trans rt according to applicable international and national gover en regulations"
<br /> PrintediTyped Name SI nature DatePff
<br /> 4, TRANSPORTER 1 DDRESS: Phone C t. ' 9 ) „� '1�, -I ISE
<br /> �!
<br /> `•j I , This is it -I`1it401.1gil •`yhili1ttC' , t Applicable Permit Numbers,
<br /> •IiI8 } 5 S�r S
<br /> pp A {-Z 'r'iftgf3l'Kit'rd r•«t .
<br /> N Sit3f iClt� CA 91 '5206
<br /> L Z< TRANSPORTER=CAT ON: Recelpt of medical waste as described ve.
<br /> Prinifrype Name _M,� n �1 �� . Signature !n Data 0yAA;
<br /> 6. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> N W
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> PrinVrype Name Signature Data
<br /> 8, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> R INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> ^ PrinVisype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> s gnetea'F ��++N-E,L1 $P S Alternate Facility: 8C. ARnnete Fscllfty; 8D. ANemele Facility:
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<br /> J A�'tI'AV [) ( ) , ( ) n , � nta 1l ., ric'n , Irtc
<br /> a '7t ' S r A Bridoeford r d , g0 Ik F %boiso � , 's177 ,6 26th Sl t ° , t r , +;a NE
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<br /> Wit• olaon , l-:%'� �I'4�it09 2 22 Noil S3ft1. nl'. lr , UTE:11064 �.ierri � r' " 5
<br /> � n , Ct•1. '?005 •_ Fr� r31 Cly: � 7a0 •
<br /> w (? 'x+ )29 - 7491 (apt �106tt1 - 1171 (8fig )7 $ 34427. (505 )303- 1106: '90
<br /> s�c TwLATMENTO&
<br /> - a0 : rpt-=; ' BrJ - �• ci Perm'sr ;� ?5j
<br /> 0
<br /> TR �e 1 been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> I= rec M97ndicated wastes n accordance with the requirement outlined in that authorization .
<br /> 10
<br /> Print/Type Name Signature Dale
<br /> ORIGINAL
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