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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stencycle iN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800.424.9300 STANDARD MANIFEST 001 .03.21 •N0CA
<br /> ' Routo #4 703 - 16 CUSTOMER N0. 21132 MDTI<0001<86
<br /> I . Generator's Name, Address and Telephone Number
<br /> 1Y TN :DIA Eric Crowley
<br /> 'fCil<ItY Dii1
<br /> l YS15- UAVI171 �t?_ U1Ui
<br /> 3 #12 S FAIRMOTNIT AVE '2022
<br /> I.. ODI , CA 95240- 3840 (209) 369 - 5410
<br /> 6U53303 -UO •I
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION K
<br /> 2A. DESCRIPTION OF WASTE 5. CONTAINER TYPE 2C, NO. OF 213. VOLUME
<br /> 6 23p9G11I Regulated Medical Waste, 11.0.13., (' �j lrl .(13fo) Pte '14 - (I� affi)� i �f 1d -( ilieinerr� to) � h Gal. "'ll) (ecrtlh7q3 , 1Cu Ft.
<br /> UN3291 RegulatedMedlcalWaste, n.O.s., '1 .;121 -([3fp }_,._ _ TP15 -(Palh )_„�WTY1 !i -( Gheino )�,� 20 Gaf . 1111) (2 .7 CO .)
<br /> 6. 21 13011Cu Ft.
<br /> CC 82,UN3291 Regulated
<br /> Regulated Medical Waste, n.O.s• , ' I Irl l�a _([jIU � I Yri !? - (�% fiG {11d } f I� ( IliCfrlU1'i�tU} l Gal . Tit ) (11 . 0 (; tilt . ) Cu Ft.
<br /> UN3291PGIRegulated Medical Waste, n.o.s., W0434131a ) CIAA3 -(Chomo ) tAP 43 -( 1' haim ) 43 Gal . 'Tti ) ( 5 . 7Ctift .)
<br /> Cu Ft.
<br /> IZ 62, PGIIRegulated Medical Waste, n.os., U Gala Coritir3atcd Box (4 , 32 CO . )
<br /> 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 /> 6.21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.2, PG11 Cu Ft.
<br /> UN3291 Regulated Medical Waste, 11601130)
<br /> 6,2, PGII Cu FI.
<br /> 3. Generator's Certification : 01 hereby declare that the contents of this consignment are fully and accurately TOTALS POP 53 , Cu Fts
<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 tra sport accords g to applicable international and national governmental regulations"
<br /> r
<br /> Printed/Typed Name O Signature Ot Date 9" 2Z
<br /> C TRAN&t'
<br /> PRIER t bDRESS ; phone N;
<br /> ' t '
<br /> A : lryC t: , 11100 . ThIS I5 %1 I III'AUgh Shipment Applicable Permit Numbers:
<br /> 7075 F A Hrldfjof'ord 1 `41 . TS10S "iM• 80
<br /> 1,110ckt0tl , c,A 95206
<br /> a CQ TFIANSPORTIER.QERTIFIC
<br /> (pl��fi Receipt of medical waste as descrihadmobove,
<br /> ZPrin a Nama (�,, �Y t�YAMMMMMMM
<br /> Q<�:
<br /> Viyp WA• �t Signature ra Date v
<br /> 5. INTERMEDIATE HANDIER 2 / TRANSPORTER 2 ADDRESS: Phone N ;
<br /> a � Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PilnVType Name Signature Date
<br /> UJIC INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N;
<br /> Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinUrype Name Signature Date
<br /> 7. DISCREPANCY INDICATION MOM
<br /> Deeigniitid Fag1 AN,E( ISE ttemsts Facility: E) 8C, Alternate Facllity: SD, Altemate Facility:
<br /> �at� I �yrl� , tnc . l%E�
<br /> Ste yclN , lnc . ( in �_ inurotr Stericy le , Inc . (Autoclave) Cuvantrt Marlon , Inc
<br /> U 7V 6 P% A Briclgei�� rct jhav
<br /> Foxbarr, Driw3 7. 770 F , 26th St , 4850 Crooklafo: roast WE
<br /> ; tcbon , CA "�y$ 6 Salt Lake , UT 84064 Vernon , GA 800 k" Brooks , OR 97306
<br /> If
<br /> z (1 1 )191 -"r 11 , r � 1 2022 93h - 1171 ( 666 ) 70on7r122 (505 )393" 0890
<br /> UJI
<br /> a 't _ 0131l= a0 08MA- 36 P* rwlt # 384
<br /> a 7R tfLt�t yetbeen authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F- receive tea ova dance with the requirement outlined In that authorization .
<br /> Pdntflype Name Signature Date
<br /> ORIGINAL
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