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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 0i e* Stericycle� IN CASE OF EMERGENCY CONTACT: CNEMTREC 1 -8004244300 STANDARD MANIFEST 00t •03A21 •N0CA
<br /> ' Route #. 703 - 11 CUSTOMER NO. 2t132 MUK00OWT4
<br /> 1 . Generator's Name, Address and Telephone Number f f # I
<br /> TOKAY GIALY Sia OAViTA #20161 [ I 11111 11 R 11 } 1 114111111111
<br /> 312 S FAIRMONTAVE 8/3012022
<br /> LOD11 CA95240- 3840 ( 209) 3Gy- 418
<br /> Gn5331� 3 - n0 `!
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION M
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. Not OF 2D. VOLUME
<br /> 623 G{iRegulatedMedicalWaste, n.o.s., T1314 - ( BIo )S.TP14 - ( Path ) TY 'I4- (Incinerate: ) 44 GaloTi '1.7C ( bT61J
<br /> Cu F1.
<br /> UN3291 Regulated Medical Waste, no.s., T1321 -(Bio ). TP1 -5-(Path )____,- TY15-( Chemo ) _,_, 2DGa1 . Tu (2 .7CLIft . )
<br /> 62, PG11 Cu Ft,
<br /> O UUN3229G1i1Regulated Medical Waste, n.o.s. , Tl'4n-( Bio ) _TY49r (Chemo )_____T14t3-( lneinerate ) •
<br /> 6,21 37 Gal . Tub (4 . Q Cu . ) Cu Ft.
<br /> 623PG1im 1 Regulated Medical Waste, n.o.s„ V�B4 3-( BIO ) C'�Atd - (Chajwno ) WX43-(Phawrt ) 43 Gal . TUb ( F . t , uf . Cu Fi.
<br /> W UN3291 Regulated Medical Waste, n,o.s., �,
<br /> Z 6.2. PGII KR (Bio ) Gal . Corrugated Box (4 . 32 Cuft . ) 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, PGI1 Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PG11 Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII
<br /> CU Ft
<br /> 3. Generator's Certification: 01 hereby declare that the contents of this consignment are fully and accurately TOTALS 11mo
<br /> described above by the proper shipping name, anSt'are classified, packaged, marked and labelled/placarded, and IJA
<br /> are In all respects in proper condition for transport according
<br /> to�applicable International and national governmental re ulallons"
<br /> Printed/i Name
<br /> �S ' , U e' e'i Si nature y / ' oats
<br /> 4. TRANSPORTER 1 ADDRESS: Phone M: ( j9) 294_ 7 $114
<br /> Q µ�j staricyde . iI1G' 4 This iu m Thr ot,i �►„' h Shipi el I Applicable Permit Numbers:
<br /> 7 `r'175 R A Bridgeforr1 Rd . TSJ4 T 00
<br /> S Stockton , CA 952.06
<br /> a oQC
<br /> TRANSPORTER FICATIr/9P ecelpt of medical waste as descri ,'�.l,J/1
<br /> ~ Print rype Name CJG�? �- " Signature < "r Date � �` ' ��
<br /> 5. INTERMEDIATE HANDLER 21TRANSPORTER 2 ADDRESS: Phone N.
<br /> a � Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print%pe Name Signature Dale
<br /> S. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Printrrype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 8A. Designat ll' Lq BB. Alternate Facilky: [� 8C. Alternate Facility: 8D. Afhmn% Facility:
<br /> v 8tericyri� EIJBve) . „ Stericyole , Inc . (Incinerator) Stericycle , Inc . (Autoclave) Covarrta tqv9arion , Inc ,
<br /> :•7675 RA Bn'dgeford Pd . 9 N . Foxboro Drive 2775 E . 26th 5t, 4860 Brooklake Road NE j
<br /> LL it 01(1 - ANorth Salt Lake , UT 84Q54 Vernon , CA 90058 Eerooks, OR 97306 II
<br /> Z :(309)2 a - 19 ( 801 )rl38- 3771 (386 )783-7422 (505 )?93 - 0390
<br /> 2 i sft s ]i 813 Permit # 364
<br /> F-
<br /> lot IrREAJ 4ITif
<br /> ave been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br /> t— received the above indicated wastes Anaccordance with the requirement outlined in that authorization.
<br /> Print/Type Name Signature Dale
<br /> ORIGINAL
<br />
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