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MEDICAL WASTE TRACKING FORM NUMBER
<br /> ��'�� Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 "8004244300 STANDARD MANIFEST 0D1 •03.21 •N0CA
<br /> Route #. 703 -• 11 CUSTOMER NO. 21132 MDTK000WT4
<br /> I . Generator's Name, Address and Telephone Number
<br /> TOKAY DIAD SI VAViTA #20 .16 1 X1111 f 1111 � � 111 � 1 1 l l11110111
<br /> 312 S FAIRMONTAVE 8/3012022
<br /> LOD] , CA05240- 3840 ( 200) 3694418
<br /> 6053303 -001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION M
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINERTYPE 2C. Nos OF 2D. VOLUME
<br /> I�CO( T. � E
<br /> UN3291 Reguiated Medical Waste, n.os., TX14 - ( Bio ) TP1d -( Path ) T114-( Incinerate ) QQ Ca . TI !1s.2, PGIi Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s., TB2 .1 - Bla TPI a- Path TY1 • Chemo 20 Gal . Tu 2 .7 Cuff . Cu Ft.
<br /> 62, PGII ( � �� ( _ .. ) _ ( )
<br /> M 623PG1 ` RegulatetlMedlcalWaste, n ,o,s„ TBgn_(Bio ) ,_„TY490 (Chenix )..,,-„_,TI403 ( Incinerate ) 37 Gal , Tub (4 . 9 Cu '. } Cu Ft.
<br /> 623PGiiRegulatedMedicalWaste, n,o.s., we4s_( Bio } C6\A?t43- (Chemo ), WX43-(PhatTi) 2 GaI . TUh ( F . + , uf . � Cu Ft,
<br /> W UN3291 Regulated Medical Waste, n.o.s., }C1 : Elio Gal . Corrugated Eo;< !8 , 32 CUft.
<br /> Lu 6.2, PGI) ( } ( } 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 /> UN3291 Regulated Medical Waste, tt,o.s.,
<br /> 62, PGIi
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s.,
<br /> 62, PGti u Ft
<br /> 3, Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS I , Cu Ft.
<br /> described above by the proper shipping name, an3Yare classified, packaged, marked and labeilad/placarded, and
<br /> are in all respects in proper condition for transport according to applicable International and national governmental regulations
<br /> ”Print Name �S � i Si natureondi Data ' or Q
<br /> cc 4. TRANSPOATER 1 ADDRESS: Phone M: ( 209) 2844 .114
<br /> . rtGCIC CIC ; Inc . -i ;i10 iS 51hr0iigv1i yiiifNfYiwfii Applicable Permit Numbers:
<br /> 71; 75 R A 8ritt0eforil Rd . T'3/01 80
<br /> N
<br /> Stockloli , CA 05206 I
<br /> a < TRANSPORT=CJ00
<br /> FICA1i9eceipt of medical waste as descri .
<br /> Print/Type Name `-= 1 Signature �r~"� - Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone No
<br /> a � Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br /> Print/Type Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: phone M:
<br /> a
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinVrype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> &jL DaalynatA GA A 88 . ARemab Facility: (� 8C. Atternate Faclltty: 86, ARemats Facility:
<br /> 0010 v 8teficyg4jIJk i q ve) stericycie , Inc , (Incinerator) Stericycle , Inc . (Autoclave) Cov3nta Harlon , Inc
<br /> :•7675 ESA Bridgeford Pd . 0 N . Foxboro Detre 27751~ . 26Lh St , 48NO Brooklake (goad NE
<br /> L<Ltrolct {{��U k ,�tnz2 (dant; Salt Lake , LIT ON 064 Vemon , CA 00068 Brooks, OR 47306
<br /> Z ( f70 )294 - 11 ;: ' ( 801 )938- 1171 (813(3 )783-7422 (60x)343 -0890
<br /> W -•a -
<br /> 'T'BRoS 'i - tTQ 3A-4%i 130A .,d Perrrat # 364
<br /> flit hot I
<br /> ave been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> cc
<br /> I— received the above indicated wastes In accordance with the requirement outlined in that authorization,
<br /> III I
<br /> PrinMpe Name Signature Date
<br /> ORIGINAL
<br />
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