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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 0i-0 Stericycle� IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 ' 800424.9300 STANDARD MANIFEST 001 .03.2IbN00A
<br /> !•=< r ole mli` 703 , 1 5 CUSTOMER Not 21132 ft ID 10KNO1 ? Ntl-
<br /> 1 . Generator'`s pNamr-e, Address and Telephone Number lipr }� g "� 1(A 11 � . Eric Ciot � �'� 4lfCt3S � 7: �I ' I r : �Tr�llt/t't t=11 1 Y l �;- 1 )/1�11Tf� /2f1 � 5ill ill � [ 1111" 111, 1 1 l51i!
<br /> 3112 S FAIRft4Oi`+1`tc 7 / 19/21322
<br /> E•• Wlj CA ' 5?_'4t 23840 ( 209) 3639-541
<br /> 505 ' 3 � '_ i3i31 '
<br /> CusTOMER NUMBER GENsRAToFrs RaoisrRAnoN 0
<br /> 2A, DESCRIPTION OF WASTE 204 CONTAINER TYPE 2C. NO. OF 20. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s•, , _ 6 1 _ r • CONTAINS S
<br /> 6.2, PGI) � x '11 (E' i �a ) TP1 :, ( F'•Mh )_�T1 1r1 - ( Incinerate } 44 Coal . Tub .r . Kuft ) �, Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s., i E,21 _ Bm 1 1 F 1 �' {� T ` Fr C' r' _ t-.r
<br /> 6.2, PGI1
<br /> l - ` ( ) __- 1 ( - r� f"i1t) }_ 2fl .a % I . Tu (i {:� .7 ifr . } Cu Ft.
<br /> CC UN3291 Regulated Medical Waste, f[� l -(sic }F �,-� +tii_fn_\+ GI{iG )_ T14g-0r'� ainat'a:e ) 37 G' w1 . T!r i (<I . ri Cuff. }
<br /> C Cu Ft.
<br /> Q UN3291 Regulated MedicalWaste, n,o.s., �i +?�c 1 +- !�'iG )__ � c..'? t'•_ :3- ( ierno Irl; - F'hatirl 4 ?� ' . ` r_r x . lGtlft
<br /> 6.21 PGII t. ( 1 )_ _ __ 1 ( ) __ _ d{ I ( ) cu Ft.
<br /> W UN3291 , Regulated Medical Waste, n.o.s., ti ' jG ) C� •�l . CGI'1�.1 atedG ' !� ` ' C_,'Llft. 1
<br /> Ill Z 6.2, PGII } ( . ) f Cu Ft.
<br /> aUN3291 Regulated Medical Waste, n.c.s.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n •o.s., Cu FL
<br /> 6.2, PGII
<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
<br /> F .
<br /> 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 1111P fj �. Cu Ftt
<br /> described above by the proper shipping name, and are classified, packaged, marked and labella&placarded, and
<br /> are In all respects in proper ition for transport according to applicable international and national gover ntal regulation'"
<br /> Print A003 tore Date
<br /> 4. TRANSPORTER i ADDRESS; Phone M: (.2 09 ) 294007 114
<br /> SDC `Stelsicyde , Itis . D ThI `3 N a Thl'uLigh ilii (? tile"til { Applicable Permit Numbers:
<br /> 0 787 .5 R A 1-.� r'idge,ford Rdt T 'S11k) •.; T- ufJ
<br /> N 'oiOC ls� li , i�t> f� 521313
<br /> ISE ,Zq TRANSPORTER CECRT}IFICAiTIONI ecelpt of medical waste as described above. - �
<br /> ~ PrinUType Name �J 1 KJ 1 + �� Signature �V Date / /9
<br /> 5. INTERMEDIATE HANDLER 2 ! RANSPORTER 2 ADDRESS: Phone N;
<br /> N
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER MIANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name 0 Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M;
<br /> I I Applicable Permit Numbers;
<br /> LU
<br /> C INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described stove.
<br /> i0x0 .
<br /> PrinUType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> !- 8A. Designated FacIINy: 88, Aftamsb FscllHy4 BC. Altemats Facility, 8D. Attemete Fr cliity4
<br /> J + Steriodsc.le , Inc . (Auti5e) Cvcotliunrl , Irle.
<br /> Q 7e75 RA Bridgeford Rd . 90 N . Forbury DriVe 2775 C . :6th E,t, 4850 Orooklaktj road HE
<br /> Ct_,cko (_:,90"16. 6 iift.LI ra � i �. 1 ✓i! �fA r til, Hifi tt �3t( �' 1 07 'I
<br /> t— n , 0 It HJT 7 . 1 rnon , A' <. lQ -. . fir _ A 5
<br /> �
<br /> %'4, Ito 11i �i XI, r, - 4i7i (" )73 -7f122 (;f1r5 ) 398 - Q 9C
<br /> Q i �UJI '�i' �Iji�
<br /> C TREATMENT FAC fLITl oertity that I have been authorized by the applicable state agency to accept untreated medical wastes and that ( have
<br /> t- 'received the above indicated wastes in accordance with the requirement outlined in that authorization .
<br /> PrinUType Nar� r Signature Date
<br /> 4
<br /> .9
<br /> ORIGINAL
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