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MEDICAL WASTE TRACKING FORM NUMBER
<br /> IN CASE OF EMERGENCY CONTACT. CHEMTREC 1 -804424-9300 STANDARD MANIFEST 001v03.21 •NOCA
<br /> S#@I'�C�/Cl@�
<br /> ' Roi.I'[ o *A: 706 - 12 CUSTOMER NO, 21132 ('+j] MUNK)
<br /> 1 . Generator's Name, Address and Telephone Number {
<br /> ATIN : Lri1; t : ro> =rlts.; ifIR11Nit i
<br /> l lin
<br /> 41 d3 S r
<br /> �AIRMONT AVE 6 /241 /2022
<br /> !_ C)N) f;M`12404 31'ft1D ( 209) 3139-541 no
<br /> CUSTOMER NUMBER GENERATOR'S REeISTRATtON III
<br /> 2A. DESCRIPTION OF WASTE 28, CONTAINERTYPE 2C. NO. OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n,o,s., t 1 - CONTAINE
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<br /> 7.
<br /> 62, PGii 91 Regulated Medical Waste, n.o,s., i B21 - ( In ) I P155 (Path )_•,_,__T ` 1 ( Cf'iet{i;7 ) _ _ 20 Gal . Tub ( c 7 Cuff . )
<br /> Cu Ft.
<br /> CC 623PGlIRegulated Medical
<br /> waste, n.0.s., TE;4 !'- (Plc? )__--"_�I- 'M - (Cherno ) Tlap-( incinerrte ) 3 ' Gal . Tui (R3 C �_ R . )
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<br /> UN3291 Regulated
<br /> Regulated Medical Waste, n.o,s., �ti; ct_(• Plci)_ _ I �; _•-(Cf7Eril0 )� _ Edi it -( (' 1' R'r1 )__, ,4 •"_. Gal . Tu ( if, 17C'LIf ) 5
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<br /> UJI W 623PGIiRegulated Medical
<br /> Waste, n,O.s., 1� _ —fdlp ) y,` al . Convrjslted BUY. ( 4 , 32 Cult. )
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<br /> UN3291 Regulated Medical Waste, n,o,s.,
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<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„
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<br /> 3. Generator's Ceriificatlon : "I hereby declare that the contents of this consignment are fully and accurately TOTALSPop
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelied/piacarded, and Cu Pt,
<br /> are In all respects In proper condition for transport according to applicable International and national governmental regula
<br /> .` z
<br /> Print Name ro Data
<br /> 4. TRANSP6RTER 1 ADDRESS: PhoneR: ( 2(19) 294 -7114
<br /> w `' 1c31'IC CI (, , I110 . - � 1 ilio it; Tf; i•Ul1sI� t7mr ; il� tl'tr' 1it Applicable Permit Numbers:
<br /> 71,"P745 R1 {3 !'irirft;ft' cicf , i
<br /> a ,Monr CA G5206
<br /> nom. TQC TRANSPORT95P4.ERTIFICATIOI(t,.-1: Receipt of medical waste as describe
<br /> ~ Printrrype Name Y\ Signature t� Signature t� t l Date
<br /> 5. INTERMEDIATE HANDIER 2 / TRANSPORTER 2 ADDRESS: Phone M:
<br /> ev � Applicable Permit Numbers:
<br /> I
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinMpe Name Signature Date
<br /> M e. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone k:
<br /> Applicable Permit Numbers:
<br /> S j Z INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Z
<br /> Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 8A, Designated Facility, 88. Alternate Facility: 8C. Altemata Faclifty: 8D. Atbmsts Facility:
<br /> :3 23t'erioyol .e , Inc . (Autoclave ) yterionvede , Inr. (1nciner2tor) SLsrioy_le , Ina . (Autool8ve) C:G4 ? rtta Harlon , Ino
<br /> q 713 5 f? t1 ridyeford Pd . .01 it) . Fovbon:, Otitic iF c . 26t1t S L, fc5t1 i1ro1j1cialke Road P1
<br /> LL Stricltton , CA 105200 North :3211 Laid; , U1" 841164 Vernon . CA MOM Brooks, OR �47305
<br /> z * (200 )29 1 - 71 i11 (801 ) q"o' $ - 1171 (81138 )7 $ 341422
<br /> g 165 1 Pernwji # , Oil
<br /> TREATMENT FACILiTYpi certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br /> t— received the above indIcaled
<br /> t wastes In accordance with the requirement outlined In that authorization .
<br /> in PrinMpe Name .' 1 ifs! 27 21) 22 i Signature Date
<br /> ORIGINAL
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