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MEDICAL WASTE TRACKING FORM NUMBER
<br /> '4o Stericycle� aH CASE Of EMERGENCY CONTACT: CNEMTREC 1800 424 930D STANDARD MANIFEST 001 .03.21 -NOCA
<br /> '7 ROLIte f: 703 - 17 CUSTOMER N0. 21132 MDTKrQ00QK
<br /> 1 . Generator's Name, Address and Telephone Number I f
<br /> Tt� l�l',Y GI /�tLY •alS- DI�1. l "i'I� 112016 � � � 3@ � <
<br /> Lill z
<br /> i412 S FAIRfv1ONTAI E 6 /28/2022
<br /> LORI , CA952j',• 0- 3310 ( 209 ) 3699 5413
<br /> CusTOMEn NUMBER GENERATOR'S REGISTRATION if
<br /> 2A, DESCRIPTION OF WASTE 208 CONTAINERTYPE 2C, Not OF 20. VOLUME
<br /> 1 tCONTAIN
<br /> UN3291 Regulated Medical Waste, n.o,s., i
<br /> 6,21 PGI) r '1 �i - (t' io ) _.rP9c ( Fath ) 7 ( E .1 -( Inaint=rate } �_� _ a sl . Tub �, C{Cuf= ) �j � + Cu FL
<br /> UN3291 Regulated Medical Waste, n.e,s., E; 21 - (Ei0 I ;"' 9 iia# I't TY15- Cli ' rrirl �'l� Cral . Tub 2 .7 Criit .
<br /> 6.2, PGI L.__ ( }._....._. ( ) r ( ) Cu Ft.
<br /> OUN3291 Regulated Medical Waste, X10 I Y4 9' C i e m t) 114 til- I nc� nei .ate 7 13all 'i !I a 4 . q CI_ift .
<br /> 6,2, PGI{ ( ) - ( )- ---�' ( ) Cu Ft.
<br /> Cr 623PGIi291 RegulaledMedicalWaste, n.o,s., Vk2D,1 "_( Bi4 ) _C"VI { ! _•- (Chern[j )_ 1"�f;{d -( PlialT,i ) 42 3ifal . '!U7 ( 5 . 7C' lli# . j
<br /> Cu Fl.
<br /> iii UN3291 , Regulated Medical Waste, n.o.s„ i `R !~iq �7y1 . COIn.r # Ftp i✓OX "! , .? CUf#.
<br /> Z
<br /> 6.2, PG II _ ( } _ f3 - - - ( �' } Cu Ft:
<br /> UUN3229911' Regulated Medical Waste, ri.o.s., 10 ir
<br /> 1r + r . Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s„
<br /> 6.2, PGIl Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGIi Cu Ft.
<br /> UN3291 Regulated Medical Waste, mo.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 110� 7w 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 /> X Pdnted/T ped Name rips C) Si nature Date
<br /> 4. TRANSPORTER 1 ADDRESS; Phone No 7944 114
<br /> w •� fc. rilyl; i {. , Itlti: . El '1 his is 9 'ffir=1L1 (tftShipment Applicable Permit Numbers;
<br /> N `: five 'rtoit , CA 55206
<br /> K Z TRANSPORTER CERTIFICATION: Receipt of medical waste as described a
<br /> PrinUType Name Signature Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; Phone N:
<br /> rz Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinVrype Name Signature Date
<br /> r; 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> a_ Applicable Permit Numbers:
<br /> a
<br /> 2 INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> MVI
<br /> PrinVType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> A. Oeetgrtated Facility: 80. Altemate Faclllty: 8C. Alternate Facility: 80, Alternate Facility:
<br /> .J ctericycle , ( coffin jh- gRtr► >65 ` t _ ri : yCle , Inc . EI {tCinf? rStOr� Steric_yi. If'Iv (Ft, itOCie,V@� CC�!r' ntii i,'l ,�rion , Inc
<br /> a '7876 Nlfft�r' iiJ ILI 90 N . Foxboro Drive 2775 E . Eith St, /f650 brookialke Fem.id HE
<br /> k ��toc{cton . Tit 9a2f . s ; (tl ,, rtf� Salt L 3{,c , lJ i � at7r4 w!,_mnn , r; '�iggagroofi , �,"' 973C� :�
<br /> 09 20 rl � U fl 2022 ( Ci1 )11W1171 (s; s8 )7 �1� -7A22 (5gti }?9?- q�. arl
<br /> 'I' SfraaT, 60 :�r4,-•}, 1r_:fJt; +�t F1k rn.ltt+ u[�i
<br /> Q ( ,�;G �tYlk
<br /> LU � TREATMENT F ortify chat I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> t•- received the ab v d�cated Wastes In accordance with the requirement outlined In that authorization.
<br /> I
<br /> PrinVrype Name qq +q� Signature Date
<br /> , , i
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