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MEDICAL WASTE TRACKING FORM NUMBER
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<br /> �i s9 S#ericycleIN CASE OFMERGENCY CQ�TACT: C�HEMTREC 1 -900-424-9300 STANDARD MANIFEST 001 .03.21-HOCA
<br /> QltlU ( u6 - � G CUSTOMER No. 21132 (v1rjTK000 *i KT
<br /> 1 . Generator's Name, Address and Telephone Number y It l
<br /> ATT ` : Eisic C1Clal '
<br /> TLrlY }tIL / SfS - Drcr 1Tfff I1 6
<br /> 3 '12 S F'AIRNtON-f AVE 9/ / 612022
<br /> LOU , CA 95211- 0+* M40 ( 209 ) 369 541 F
<br /> aai] 5a ?� p � - Op1
<br /> CUSTOMER NUMBER GENERATOR'S REMTRArON N
<br /> 2A. DESCRIPTION OF WASTE 28• CONTAINER TYPE 2C, NO. OF 2D. VOLUME
<br /> U23 91 Regulated Medical Waste, n.o,s., T B1a - (Bio ) ,TF` 14 -( Path ) TV ' I4 - ( Inoinerat_ ) W � 44 Cotiai . T .II��T�� r . 1
<br /> cu Ft,
<br /> TP1F-(Pal:11L_ t`** 3--( Chrno �63Regulated Medical Waste, n.o.s., � 20 oaf , Tu (2 . 1 Cult, . )
<br /> _ Cu Ft.
<br /> M UN3291 Regulated Medical Waste, n.o.s,, T Btln_ Bio TV/-1Q'- Chenlo i fa t- IrtCin �4'3te ? 7 oaf Tub 4 , n k�'t ft,
<br /> 6.2, PGII ( ) —.— ( )--- ( ( ) Cu Ft,
<br /> 623PGIRegulatedMedica)
<br /> Waste, n.0.s„ \�FBq -( BIG ) '�V ,La3- ( CI1? I'ito ) _ VVX43-( Pharrn ) 4 ,3 a) Tula ( , r , ta [ . )
<br /> cc Cu Ft,
<br /> Lit UN3291 Regulated Medical Waste, n.o.s., 'r; f? ( Bic ) Gal , ��on&ugated Box ( 4 . 32 Cult . )
<br /> W 6.2, PGII Cu FL
<br /> UN3291 Regulated Medical Waste, n ,o.s.,
<br /> 6.2, PGII Cu Fl.
<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 Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.21 PGIi Cu Ft
<br /> 3. Genwatof's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS lop TOTALS R 2 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 /> Printecliftlyped Name Avu Signature Date
<br /> 4, TRANS 10 T�R 1 AD�ESS: Phone N: w ) 7 - ! 1 1
<br /> cc erlcyc Inc; . EjThis i.; ; Thl'O .ic11 .: 01119:1
<br /> N r ) i Applicable Permit Nu . be
<br /> 7 „75 R A Gni idgeford P% (i . '
<br /> R Stocklon , CA 952063
<br /> TRANSPORTER C FICATIO/'Nl:11Receipt of medical waste as descri ,gyp n �f
<br /> PdnV ype Name w, wtl Signature 2 fr ► ----- f Date V L (161202 --
<br /> .� 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N :
<br /> N Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION $ Recelpt of medical waste as described above.
<br /> PrinttType Name Signature Date
<br /> M 9. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N,
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Prinl/Type Name Signature Data
<br /> 7. DISCREPANCY INDICATION
<br /> DBsip B 98, Altemais FacllRy: 9C, Alternate Facility: 9D. Altamats Facility:
<br /> Sterlc)M4JT.QCIAu90ivr-) Steri ,cude , Inc . (Indner3tor) Stericycle , Inc . (Autoclzive) Covanta klarion , Inc
<br /> 4 i �176 Rte Bridgeford Rd . 90 P1 . Foxboro Drive 2 '.'t
<br /> 775 E . 6th S,t , 4950 Brooklake Road NE
<br /> u. StocIct1SER:AJ?7-'22022 Norm Salt Lake , UT 84054 Vernon , CA 90069 0raoik _, GR 97305
<br /> X09 '291 - 71 # 4 801 9 6 -3171 9Ba 793 - 7142 ?. aGF� ' 3s�^ G9tiG
<br /> W
<br /> (r ) ( ) {' ) ( }
<br /> TSpIOS,�T,.8�0� 3kL11, 118kiq-:3cs Permit rt 364
<br /> W I ave 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 /> Print/Type Name Signature Date
<br /> ORIGINAL
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