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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 4*z Stericycle IN CASE OF EMERGENCY CONTACT: CHEMTREC IwSOD4244W STANDARD MANIFEST 001 .03.2IwNOCA
<br /> Route #. 706 ,415 CUSTOMER NO, 21132 MDTKOOORNE
<br /> 1 . Generator's Name, Address and Telephone Number l I
<br /> ATM
<br /> DIA Crit Crowley
<br /> DIA
<br /> TOKAY LYSIS- DAUITA #2016
<br /> 312 S FAIRMONTAVE 7 /8/207. 2
<br /> L ODI , CA 95240-3840 (209) 369- x416
<br /> 6053303- 001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C, N09 OF 20. VOLUME
<br /> 6 232911 Regulated Medical Waste, mo,s„ T014 -(0to).�TP14 -( Path) TY1 �4 -( inchterate ) X44 GaI . Tub ! t� n
<br /> i L Cu Ft,
<br /> UN3291 , Regulated Medical Waste, n,o,s„ TB2141:31a ) TP16i (Path). TYI540helno ) 20 Gait Tub (2 7 CuFt .)
<br /> 6,2, PGII Cu Ft.
<br /> O UN3291 Regulated Medical Waste, n,o,s„ `(' ( ,� � � 10 �6*21 ?Gil _ _ �tYht1 _(C1hanla )_ T148411nclnerata ) 37 Gat , t'U (4 *0 GO * Cu Fi.
<br /> UN3291 Regulated Medical Waste, n,o,s„ j[ 4 3 �:�AI� 3 _ C11tf tn4 r
<br /> 6.21 PGII -( t�1) ( ).1NX434Pha rtn) X43 Gal , Tu ( J . / GuFt .) Cu Fit
<br /> W UN3291 Regulated Medical Waste, n.o.s. , 32 Cu
<br /> ft.)
<br /> 1{ r1 4llo , rtu atetl Box . ft .
<br /> Z 6,2, PGII ( ) GatCfl ( ) Cu Ft.
<br /> IJJ 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 /> UN3291 Regulated Medical Waste, n,o,s„
<br /> 6,2, PGII Cu Ft.
<br /> U111329t Regulated Medical Waste, n,o,s„
<br /> 6,2, PGII Id Cu
<br /> Ft,
<br /> 3. Generator's Certification : 1 hereby declare that the contents of this consignment are fully and accurately TOTALS / r4l 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 transpo rding to applicable International and national governmental regulatlonaP
<br /> >arint Name
<br /> signature Date
<br /> 4. TRAN PORTEfl 1 ADDRESS: Phone No 294 " 7111f
<br /> tericycle , Inc . Tills Is a Through hipment Applicable Permit Numbers:
<br /> 0 7876 R A Bridgeford Rd . T8/0874� 80
<br /> ZN Stockton , CA 95206
<br /> COLE TRANSPORT TIFICATION : Receipt o1 medical waste as described0� / 2�
<br /> �n Cdh� St nature L :�^�+� IJL� to
<br /> Print/Type Name g
<br /> 6A INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> a Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Print/Type Name Signature Date
<br /> M 6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> Applicable Permit Numbers:
<br /> a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br /> PrinMpe Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 8A. oaslpnetic AM" Be. Aftemate Facility: ❑ 8c. Altemale Facility: 8D. Altemeh Facility:
<br /> W 0tericycIdA, t a ) Sterlcycle , Inc , (incinerator) Stericycle , Inc . (AWOClAve) Covantaa Marlon , Inc
<br /> 7876 RA ridgilft rd lid , 90 N , Foxboro Drlv3 2776 E , 26th St, 4860 Brooklake Road MF.
<br /> u<,
<br /> Stocktorl� ��t 91 t2 � 2z North Suit Lake , UT 8(1054 Vernon , CA 90058 Brooks, OR 97306
<br /> W (203 )294 -711 1 ( 801 )939- 1171 (8613 )7834422 ( r03 ) "mago
<br /> TSiQ 6T' 60 / 3Aw448/JA413 Part ilit F 389
<br /> have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> P received the above indicated wastes in accordance with the requirement outlined In that authorization,
<br /> Print/Typo Name Signature Date
<br /> ORIGINAL
<br />
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