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MEDICAL WASTE TRACKING FORM NUMBER
<br /> �i i� Stericycle° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -600-424.9300 STANDARD MANIFEST 001 .03&21 •NOCA
<br /> Route :LE 70' - IO CUSTOMER NO, 21132 Pt4I;tTIfi00Qf;7F' 1
<br /> I . Generator's Name, Address and Telephone Number
<br /> -� I �{ ��� 4aI4Crowley� �� L, � >; Ili i i I E ; i iii jot J M !� 111 � 1A
<br /> 312 S FAIRMONT1 VE 7 /5/20122
<br /> LODI , CR. 95240380440 ( 209)0 369- 5418
<br /> 6053303•. a I
<br /> CusTOMEn NUMBER GENERATon,s REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C, Nos 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n,o.s„ TF '1 �.1- Fitt TP1a - P .. th 7Y '14� Irloirterate n co LTAf ERs
<br /> 6.2. PGII ( )_� _ ( ) ( ) �1 ��%sI . Tub ( , ,cs ta'�E�10 �
<br /> 5
<br /> V Cu Ft.
<br /> 6232911 Regulated Medical Waste, n,e,s„ TF2 .1 -( SIG ) TP15- (Path )�,•,_TY •1 `�-( Chi; t-110 )� _ 20 GPI . Tub ( 7 Cuff . ) Cu Ft.
<br /> tY UN3291 Regulated Medical Waste, n.o.s., TEALt - (FID )__�IY�is - (CfleCriOj ___`1110-( inwdnel'ete ) I T IF (� . )
<br /> 0 6.2. PGII 37 Gal , u .1 C!tlt• Cu Ft,
<br /> UN3291 Regulated Medical Waste, n,c.s„ +• ;P4c;_( lala}�„ __CV1�10- (Cf'�SYr1o )_ V\/K+ 13-( F'h tT'It ) � _ 3 T Wil . Tll1 ( a . 7t !tit . }
<br /> Cu Ft,
<br /> W UN3291 Regulated Medical Waste, n.o,s., }` ia10 !'+ SI , C01'ttt� •ated FOA !1 , :;2 Cl1fi .
<br /> `Z 6.2, PGII ......Y...( ) _ _ _—_ ` c1 ( ) Cu Ft.
<br /> Vr UN3291 Regulated Medical Waste, mosso,
<br /> 6.20 PGII Cu Ft.
<br /> UUN3229G11I Regulated Medical Waste, n .os.,
<br /> 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 /> 6,21 PGII Cu Ft.
<br /> 3. Generator's Certification : "I hereby declare that the contents of this consignment are fully and accurately TOTALS Oppn C� ) '[ r 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 transport according to applicable International and national gover mental reg Iations:'
<br /> f
<br /> ! Printedlryped Name Signature Date '
<br /> 4. TRANSPORTER 1 AD RESS ; Phone #., ,_' ti 3} ;1 +1. _ �1
<br /> a `atOI1C� CIC , IIC . [] T Ills Is a 7 I1rOLICI7 s hi}y111Ct;t Applicable Permit Numbers;
<br /> CC>M '1875 R A I� 1'Idgeford R(t . T4ilj? a 1 8
<br /> a �; 1oddon , CA 9"5206
<br /> a TRANSPORT RTIFICATION : Receipt of medical waste as described ve,
<br /> F' PrinMpa Name TuV � tn Signature Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br /> Phone #:
<br /> gCC
<br /> Applicable Permit Numbers:
<br /> w
<br /> g2o
<br /> u, 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 /> S ° Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION:' Receipt of medical waste as described above.
<br /> — Ptinl/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> _
<br /> N/Ah
<br /> if pkv - �v
<br /> 8A , DeatgnatetiPA1111111Y 1 8B. Alternate Facility, tJ 80, Alternate Facility: E] 80. Alternate Facility:
<br /> ' rcrl11
<br /> cyale !I 4lY ,4lA, > + ) ` tericycf_ , Int . (Incinerator) Stet+cycle , Inc . (Autoclav ) Co :ranta ;:.trlorl , Inc.
<br /> 4 71375*RA Bridgefor�d Rd . 10 N . Fo'/,t.+aro Dnvgn 2775 Et 26th St, '1350 Droottlake Fuad NE
<br /> u� Stocl:t, 1111JULrf ,{�:t i InIth Salt take . UT 134054 Vernon , CA 1100 ,68 Drooka, (:R 97305
<br /> Z $. (2G@ )2P& 71 i4 kERGI 9313 - 1171 (+30i )78^ _ 7422 (5105 )313-0890
<br /> W T910 80 )AA118r:)A- 336 Permit: itt 36tj
<br /> W THEA (1'I"FACfLi1 Yt 1'cetttfythat have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> h received the above Indicated wastes In accordance with the requirement outlined in that authorization,
<br /> A CN
<br /> PrinMpe Name Signature Date
<br /> IS 01
<br /> ORIGINAL
<br />
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