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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 4049 Stencycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 14800.4249300 STANDARD MANIFEST 001•03.21 •N0CA
<br /> . ROLllts s!. 703 - 11 CUSTOMER NO. 21132 MrJTKO00YU1
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATTTt KIW DIA Y `SIS' WI / 420163 l if l f l f f ff I f # f f f l f
<br /> 312 1 FAIRtt. ONTJ V17 9 /20/2022
<br /> LOU ) CA 952110 " 3040 ( 209) 36O-5 -f '18
<br /> 60533031- 001
<br /> CUSTOMER NUMBER GENERATOR'S REousTRAnoN N
<br /> 2A. DESCRIPTION OF WASTE 20, CONTAINER TYPE 2C. NO, OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n,os„ „ _ , _ , , Q " _ G r � CONT INER
<br /> 6.2, PGI► TB'1 ltEO )_ ___Tt' 11 ( Petit) _ T`r11 ( Inoin _ I �t _ )_ '11 a I fiU ( , . tCuti}� Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, 1`011 TF,21 ( iiTt' 1cf� th i Y15- Ch3nio )_ 20 Gal , 1ut (2 .7 Cuft .
<br /> ) Cu Ft.
<br /> CUN3291PGIRegulated Medical Waste, n.os„ I E1J-( ia ) _% TY4R- (Gh� rnu ) _ _-T IQ -0licinGt'=te ) 37 �-� al . '1�ub 0 . 161 Cu 1. ) Cu FI.
<br /> a 023291► Regulated Medical Waste, n.o.s., \;;;Es3-( fVl'•1 ,-(,Chi ilio )_ _ \� JK43-( Phatin ) x-13 Gal , Tub ( 6 .if . J
<br /> cc Cu Ft.
<br /> W t�OX (
<br /> UN3291 Regulated Medical Waste, n.o.s., ( ) Gal . L: Ot't11� a ,3 Pio lte4 . 2 Cuft. )
<br /> t2 6.2, PGIi Cu Ft.
<br /> Vr UN3291 Regulated Medical Waste, n ,o.s. ,
<br /> 6.21 PGII 4 . t Cu Ft,
<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGil Cu Ft.
<br /> UN3291 Regulated Medical Waste, n ,o.s,, Cu FL
<br /> 6.2, PGiJ
<br /> UN3291 Regulated Medical Waste, n.o.s. ,
<br /> 6.2, PGIi Cu
<br /> Ft,
<br /> SHOPS
<br /> 3. Generator's Certification: "I hereby declare that the contents of this corisignmgnt are fully and accurately =TOTALS l 2 . Cu FL
<br /> described above by the proper shipping name, and are classified, pa aged, marked and labelled/placarded, and
<br /> are In all respects in proper condition for Iriinsport aording t ap ; bla Inlernational and national governme al ragul ns"
<br /> i Name M11tore Date is
<br /> 4. TRANSPORTER 1 ADDRESS: Phone N: ( 200) 2944114
<br /> °C sfvltt:ifcl4', , inc • I KIfit ► ► ; T{ ir tllalt :::hIpinen# Applicable Permit Numbers,
<br /> 7875 RA Bridg �tford Rds �_`' I""4l�iti; 'f SG
<br /> N t�wmlocklont CA X15206
<br /> off. TRANSPORTER CWFICATION: Receipt of medical waste as de ve.
<br /> PdnVType Name V Vf�t1 logSlgnature���= �t� p Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone If.
<br /> a k" Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> PdnViype Name Signature Date
<br /> 6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M :
<br /> . Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATIONi A9ceipt of medical waste as described above,
<br /> PrinVrype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 6A. Deaig/nn�a��tJi 88. Altercate Facility; SC, Attemata Facility: 80, Altemato Facility: f
<br /> teftC;'uT Tt ;t . ( d 9cl iva ) aterictfC•1e , Inc . (fncinhratur) .tt?floirf::le , Inc . (}lrlttCl3\%°) 00 ( OVABk r N6Slon0Ina �
<br /> v
<br /> 787 5 P B d e�+ d . 20111 . Font oro Drive '1. 715 I✓ . 25th 'St, li86U' MrooklAne"VRo N�
<br /> it '� toc , CC; � 4PC RtortiSalt Lake , UT 84054 Vernon , CA006st F3rooks , ��� 7�Or
<br /> (209 )29 # - 71 -11 (2n_ I ) 938-1171 ( 866 ) 783-7 :; ' ? (505 )3 :.- � nIG i 2022
<br /> Tmc;rnS T-80 Perry it ' 3,6
<br /> certify a I have been authorized by the applicable state agency to accept untreated medical wasteSl% have
<br /> received the above indicated wastes In accordance with the requirement outlined In that authorization .
<br /> GO I
<br /> PdnVType Name Signature Date
<br /> ORIGINAL
<br />
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