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ioy IN CASE OF EMERGENCY CONTACT: CHEMTREC 14W 424.93W MEDICS` WASTE TRACKING 00 GFORM AUMBER
<br /> Stericycle CUSTOMER N0. 21132
<br /> 1 . Generator's Name, Address and Telephone "A 7034 NpT( MICIM
<br /> ATTN: Er;I CiY 0li l I1111111Illi iI I #� III �11I I I# I IiI I I #i # II # #
<br /> TOiCAY atAt.YSIB- DAVIDAViTA X2016
<br /> 312 S FAIRMONTAVE 10/11/2022
<br /> LORI , BA 95240-3840 (209) 369-5418
<br /> Cus1oNER NuMaeR GENERATOR'S REoisrnAnoN M
<br /> 2A. DESCRIPTION OF WASTE No CONTAINER TYPE 20. Not OF 20. VOLUME
<br /> UN3291 , Regulated Medical Waste, n.o.s., CONTAINERS
<br /> 6.21 PGII Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.s• , 10 - a ncinera G a . I U
<br /> 6.21 PGiI Cu Ft.
<br /> Ir UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Fl.
<br /> QUN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Ft.
<br /> LU UN3291 Regulated Medical Waste, n .o.s. , 6al . To
<br /> `Z 6.2, PGII
<br /> UN3291 Regulated Medical Waste, n.o.s., +%32 * Cu F!.
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII
<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 Cu
<br /> Ft.
<br /> 3. Generator's C*rtificatlon: "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 ail respects in proper condition for transport according to applicable International and national governmental regulations."
<br /> PftoaWW Name tii Hato Dan
<br /> 4. TRANSPORTER 1 ADDRESS: Phone N• 91/ 2944114
<br /> Stencycle, Inc . This is a Through Shipmert Appiicaba Permit Numbers:
<br /> a 7875 R A Biidgeford Rd. TS/UST 80
<br /> Stockton , GA 95206
<br /> a pZq TRANSPORTER CERDFICATION. Receipt o medical waste as descri boy, 1 ` J
<br /> ~ PrinVrype Name i n Signature . r �u' J LYLr</ 4 PQ.91 rftm� Date
<br /> S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: phone N;
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> S. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS ; Phone N:
<br /> av Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION' Recdlpt of medical waste as described above.
<br /> Pdn!/Type Name Signature Date
<br /> ' 7. DISCREPANCY INDICATION
<br /> btE'A t In it [ $Co AN Facl bD. A Fac iky:
<br /> elicyWAChaves
<br /> lot e , e (nainerator) �tencyc91 C . � utoclave) , vantaon , �no
<br /> v 7876 d . 90 N . Foxboro DrivIe 2776 E . 26th St, 4860 Brooklake Road NE
<br /> Stack North Salt Lake , UT 84054 Vernon , CA 90058 Brooks , OR 97305
<br /> ��09)19441gg4 r (801 )936. 1171 (866)783••7422 (605)398- tl890
<br /> W ;~fsla F 12 2022 ' SA448MA-36 Permit # 3N
<br /> iu
<br /> i-
<br /> TREA FA �t'• tlfy that I ave been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> Imo- r otts.Jradtaa3o ccordance with the requirement outlined in that authorization ,
<br /> Prini/Type Name Signature Date
<br />
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