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MEDICAWA TM TRACKING FORM ER
<br /> ZyStericycleIN CASE OF EMERGENCY CONTACT: CHEMTREC 1460042443W STANDARD CA
<br /> ROule # 706 . 17 CUSTOMER NO. 21132 MDTK00(lUWB
<br /> I . Generator's Name, Address and Telephone Number ttIic IovdeY if I
<br /> 11
<br /> TOKAY U Y 'SI GAVITA #2016 11111111 t if
<br /> i C
<br /> 312 S FAIRiMONTAVE x/26/2022
<br /> l. ODI) CA 95240-3040 1 ( 209) 3139,V#54, 18
<br /> G053 303=-001
<br /> CUSTOMER NUMBER GENERATOR's REGiSTRAWN N
<br /> 2A, DESCRIPTION OF WASTE 28• CONTAINER TYPE 2C. NO* OF 20. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s,, T I314 - (RIo )y5,TP14-(Path ) TY14 -( incinerate ) 44 Gal . T u ?er(T09
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s., TR121 •- (E3Ia ) _ _T P1 a- (Path )_,,,_- TY1 S-( Cherno )�, _ _ 20 Gal . Tu (2 .7 CUIL )
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s•, TG40- Bio TY4n�= Cheria 37 Gal . ii17 4 . 2 C. Ll
<br /> 6,2, PGII ( ) _ ( ) T14 �l-( Incinerate ) ( ) Agog, Cu Ft.
<br /> 023291 Regulated Medical Waste, n.o.s., W943-( Bio ) CVV13- (Chemo )__•_ W 42� ( Pharl�i ) du Gal , ul) ( 6 .7t�it . )
<br /> Cu Ft.
<br /> Lou UN3291 Regulated Medical Waste, n.o.s„ KR (Bio ) Gal . Corrugated Box (4 . 32 CA . )
<br /> W6.2, PGII Cu Ft.
<br /> Ogg
<br /> ca UN3291 Regulated Medical Waste, n.o,s„
<br /> 6.21 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„
<br /> 6.2, PGiI Cu FI.
<br /> UN3291 Regulated Medical Waste, mos,,
<br /> 6.2, PGII Cu Ft.
<br /> No I
<br /> 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► 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 /> Print Name w ? Signature Dote ""
<br /> 04
<br /> 4. TRANSPOPTER, 1ADDRESS: Phone N: ( 2
<br /> SIei'ti:yClP , It) G . ❑ This Iv a Ti11#011.1gll 41it titwtlt Applicable Permit Numbers;
<br /> a -1075 R A i� i'idgeford Rd .
<br /> ZR Stockton , CA 95206
<br /> W TRANSPORTER,�FICAl" ONn"Cl
<br /> f medical waste as descri
<br /> Print/Type Name . J00r? _ Signature . ' STI• ~ Date Vgggggggg Q !W
<br /> &W
<br /> 6. INTERMEDIATE HANDLER 2 / TFIANSPORTER 2 ADDRESS: Phone N :
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Pdnt/lype Name Signature Dale
<br /> 8. INTERMEDIATE HANDLER 3 / TFIANSPORTER 3 ADDRESS: Phone N:
<br /> Appllcable Permit Numbers:
<br /> X INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinMpe Name Signature Data
<br /> 3p 7. DISCREPANCY INDICATION
<br /> $A: Designated Faclltty: 89. Alternate Facility: 80. Alternate Faelitty: 80. Ahemate Facility:
<br /> j 18ier!c.y0le ; Inv. (Autoclave) Stericyole , Inc , (Inzlnerator) Stericycle , Inc. (Autocla,fe) C:ovanta Marlon , Inc
<br /> R 7875 RA Rridgeiord Rd, AO N . Foxboro Drive 27766 E . 28th St, aB5G E3rooklake Road NE
<br /> u- AU@: I3:0 , 29M0200 North Salt lake , UT 34054 Vernon , CA 00069 Brooks, OR 97305
<br /> Uj (269 )29={ - 7194 f8G1 )93E3 - 7171 (88F; )783- 7422 (5G5i )393- 6390
<br /> Tie TSIOS iwu 3A-�I�tt3l lA '3cn Permit # 364
<br /> (". .
<br /> i
<br /> pit TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the above indicated Wastes in accordance with the requirement outlined In that authorization ,
<br /> I
<br /> Print/Type Name Signature L Date
<br />
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