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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 009 Stencycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -600-4249300 STANDARD MANIFEST001 .03.21 •NOCA
<br /> Rot.}tC # 706 . 17 CUSTOMER NO. 211132 MDTK000NH6
<br /> 1 . Generator's Name, Address and Telephone Number (f ]] ff }}
<br /> ATErisCrowley
<br /> i Ta1;AY U�iALY � tS- L7A11ITA #2016
<br /> 312 S FAlFitt ONT AVE 51 7/202
<br /> LODI , CA 95240 - 1840 ( 209) 369. 5418
<br /> CUSTOMER NUMBER 605330M01 GENERATOR'S REGISTRATION M
<br /> 2A, DESCRIPTION OF WASTE 2e. CONTAINER TYPE 2C. NO. OF 2D. VOLUME
<br /> 5uS c623iRegulated Medical Waste, n.o.s„ TB14 _ ( BjO )�TP14-( PaiJ) ) � TY14 -(Incinerate ) 44fo , 3iibPG (]
<br /> r 2 Cu Ft.
<br /> 6.23291 Poll Regulated Medical Waste, n.o.s., TB214131o ) TPI6- (Path ) TY1 &( Chewr1ia )_,--__, 20 Gal . Tub (92 .7 Clift . )
<br /> Cu Ft.
<br /> Q
<br /> UN3291
<br /> 1, RegulatedMedicalWaste, n,o,s., TP40_ (Blo )_ TY40_ ( Chema ) T140-( Inelnerate ) V Cal . Tub (4 . '0 CLift, ) Gu Ft.
<br /> cc 623PGIiRegulated Medical Waste, n.o,s., VVB43-(BIO ) C1/VT3m (Chenlo )Y WX42 -(PhaiT'ri ) 4a Cal . Tu b ( 5 . 7Cuft , ) Cu Ft.
<br /> LLI UN3291 Regulated Medical Waste, n.o.s., �, o �
<br /> W 6,2, PGII KRx (BID ) ___-_-_ oal . Corrugated BOX (4 . 32 Cuft. ) Cu Ft,
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6,21 PGII Cu Ft,
<br /> UN3291 Regulated Medical Waste, n.o.s., Cu Ft.
<br /> 6,2 , PGII
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6,2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s. , Cu Ft.
<br /> 6.2, PGII
<br /> 3. Generator's Certification : 1 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 governmental regulations"
<br /> Printed/Typed Name COALM Signature Date
<br /> 4. TRANSPORTER 1 ADDRESS: Phone #: ( 209) 294_7114
<br /> Sttrncycte , inn . This i: a Thr{?t.10t1 -`_atltt ffieIIt Applicable Permit Numbers:
<br /> M 7875 R A Eridgeford Rd , TS/OST 80
<br /> N
<br /> oStockton , CA 95206
<br /> ma. q TRANSPORTER CERTIFICATION ' Receipt of medical waste as describ ve, )
<br /> Print/Type Name _ V � l 'p Signature C� {J1 � Date
<br /> S. INTERMEDIATE HANDLER 2 ( TRANSPORTER 2 ADDRESS: Phone #:
<br /> ac Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Recolpt of medical waste as described above,
<br /> I
<br /> Print/Type Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> Ua w Applicable Permit Numbers:
<br /> w -U
<br /> U a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> z �ix
<br /> — Printlrype Name Signature Date
<br /> 7, DISCREPANCY INDICATION
<br /> AXfA. Designated Facility: 813, Alternate Facility: 8C. Alternate Facility: E] 8D. Alternate Facillty:
<br /> S ericycle , , Inc . (Autoclave) • Stericycle , Inc . (incinerator) Stericycle , Inc , (/autoclave) Covanta Marian , Inc.
<br /> a
<br /> 7 ,975 R A Bridgeford Rd . 90 id , Foxboro Drive 2775 E . 28th St, 4850 Brooklake Road NE
<br /> U; Stocictan , CA 95206 North Salt Lake , LIT 84054 Vernon , CA 90055 Brookx, OR 97305
<br /> Z E9 " ,1294 .7914 . . _ _ a 1801 )''38- 1171 (888 ) 7834422 (505)393. 0890
<br /> 5ic�5 i 317 1 ` ' ' • l ! ' ' - 3 Permit # 364
<br /> Uj
<br /> REATMENT FACILITY: I certify that I t ave been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F- a ceived the abve 2d �Ji to�I wastes in cordance with the requirement outlined in that authorization.
<br /> �
<br /> rint/rype' Name Signature Date
<br /> 1 . � . . .4� 7 eel: :'
<br /> ORIGINAL
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