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MEDICAL WASTE TRACKING FORM NUMBER
<br /> {e} StericydiW IN CASE OF EMIERGENCY CONTACT: CHEMTREC 1 .80x424.9300 STANDARD MANIFEST 001 .03.21 •N00A
<br /> ' J ROUIP.' W.: 7 {) 6 4 CUSTOMER NO, 21132 MDTKOOfJXSO
<br /> 1 . Generator's DIALY� I3ess and T
<br /> Add
<br /> Name, Address Number
<br /> A �' Eric CI•o.ffl�y 1111111111111111 Ell 141111
<br /> �"Ot:l��`t' DS •• D1-lV ! `E•;t #21116
<br /> 312 S FAIRMONTAVE 902022
<br /> LORI , CA 952201- 3040 ( 205) 365- 5410
<br /> 6053303- 0 (11
<br /> CUaTI NUMBER (3ENERATOM'a REOISMITi0N N
<br /> 2A. DESCRIPTION OF WASTE 2B, CONTAINER ripE 0 0
<br /> 2C. NO. OF 2D. VOLUME
<br /> UN3291 , Regulated Medical Waste, n.o.s. CONTAINS 8
<br /> 6.21 PGII TE (810�TP144path) TY '14 -(Incinerate) 414 Gz1 . T .6 ( v .OGL 1117Cu Ft.
<br /> UN3291 ,Poll Regulated Medical Waste, n.o.s., 1071 . saiD I P �15- Path TY •15- Cherna 20 Cial . Tu 2 . 7 C' UR .
<br /> 6.2, PGII )--- ( }- ( ) ( ) Cu Ft.
<br /> 6.2. PG Regulated Medical Waste, n.o.s., l 240- 810 TY4 a- C.herr o Tf40- incinerate 3 Cat Tub 4 . 9 CL ft . Cu Ft.
<br /> 62, PGII ( ��. ( ( ) 7 ( }
<br /> 642, PG Regulated Medical Waste, n.o.s., ll t!i �- Bfo CV\F 8,I Chetno WX42 P1' ami { Gal Tub �i . , ' ILI t .
<br /> 6.2, PGO ( }_ 1 ` ( )_ _ ._ ( }_ _ 4 ( - Cu Ft.
<br /> W UN3291 , Regulated Medical Waste,
<br /> 1"; P (i } IS} J C; a1 , C; pttltL �tEdU). � . CUft .
<br /> W 6.2, PGII } g � ( � ° �' ) Cu Ft,
<br /> UN3291 Regulated Medical Waste, n.o.s,,
<br /> 6.2, PGII Cu Ft.
<br /> 6,2a 29 I Regulated Medical Waste, n.o.s.,
<br /> 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, PGII Model Ou
<br /> Ft.
<br /> 3. Generator'! Ceriiffcatfon: "I hereby declare that the contends o1 this consignment ate fully and accurst* TOTALS I1 , Cu Ft,
<br /> described above by the proper shipping Warne, and are classified, packaged, marked and labelledrplacarded, and
<br /> are In all respects In proper condition for tra according to applicable international and national governmental reoulations"
<br /> h tr�k ,r 6 D. SUNNI
<br /> 2Z
<br /> 44 TRANSPORTER 1 ADDRESS: Phone M: ( 209) 264 -7111
<br /> E lvricycte , Tills IS a `Ctti•cLIgh 3111pillottt Applicable Permit Numbers:
<br /> 7U75 R A Brietcl ,font Rd . T VOST ;tl
<br /> Ucklon , CA 95266
<br /> a TRANSPORTER C FICATt ical Recelpl of mod" waste as dasoc;" eve,
<br /> PrinVfype Name R G L Y4 SignatureK Date 0
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: r0000' Phone C
<br /> a Applleable Permit Numbered
<br /> INTERMEDIATE HANDLER ITRANSPORT'ER CERTIF1CAMON: Receipt of medical waste as described above,
<br /> Print/Type Name signature Dole
<br /> 8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone 44
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medloal waste as described above.
<br /> Printlryps Name signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 84L Deeign"O Facility: t1S. M mole ftdfty El W, A tennb Fedilly: $D. Morn to Facility:
<br /> _. 3tengycle , Inc . (Autoolamis_) Stericycl� , Ince _ (Iricini" rator) Stericycle , Inc . (Autoclave) C:ovanta I'viarion , In ,
<br /> a J5 � i�40 a`2r� R. d . 20 N , ' Foxboro - Drive 2175 6, 28th St, 48510 (virookloke Load NE
<br /> • Stookton , CA 95208 6 North Salt Lake , UT 84054 Vernon , CA 00058 Firookq�, OR 073051
<br /> (,' 09)204 -7ii �i ( 001 )'338- 1171 (388 )783-7.122 (605 )?93 0800
<br /> i frwiST E U Permit # 2264
<br /> 1 TREATMENT FACILITY: I certify that II have been authorized by the applicable state agency to acoept untreated medical wastes and that I have
<br /> f- received the above Indicated wastes in accordance with the requirement outlined In that authorization.
<br /> Print/Type Name Signature Date
<br />
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