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MEDICAL WASTE TRACKING FORM NUMBER
<br /> ':e:' Stencycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 1400.4244300 sTANDARa MANIFEST o0tvo3.21 •N0CA
<br /> RT) ttteo 31: 703 " 12 C U$TOM E A N Do 21132 hilDT1i00 .107J
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> AI '11,l . L. 11c 1 . 1D`-s' 1ey If 11 I 1 I I 1111 � ill Ili
<br /> 'fO1�r1Y [�t1lL'�' �; iS • f�fE1ll -III 1K2016
<br /> 312 S F"AIRMONTAVE Sim
<br /> L ODI , Cly 952100, , 0Nq ( 209) 3 G9- 541 no
<br /> VAN
<br /> fag54s� q �- CIq •1
<br /> CUSTOMER NUMaER GENERATORS REoisTRAT1oN ff
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO, OF 20, VOLUME
<br /> UN3291 , Regulated Medical Waste, n.os., _ • _ i _ , . f; CONTAINER
<br /> 6.2 , PGII TC1 s Gla ) TP1 < fFath ) 71 11 -, I ; I �Ifi+ t - t1—_ {1 -� Gal , T, L- ( _ • 9� ur Cu Ft.
<br /> 6a21. PG11 Regulated Medical Waste, n•o.s., - (Bio )_ � I - ((� �` S t )_ _ _ I Y S -( CI i - 1i's0 )�� 2Q !? a1 , 1 �tl (?. .7 C%Ltt . )
<br /> Cu Ft.
<br /> it UN3291 Regulated Medical Waste, n•o.s., j [�.1r_,_ Biu ;_ ! �' It' C"IiPIi1G I I , n- Ir,oinGr.01i ? 37 Gal . Tub ct . �� +:'� ; .
<br /> (� 6.2, PGII ( ( )_.._ ( ) ( ) Cu Ft.
<br /> Q UN329i Regulated Medical Waste, n.o.s., �, 1i8 :; 3 - ( Bi4 C\�ii � C. fi tilc3j \/t� �Lr �-f �liafT+i � uC% c1 . i+-iL ( '3 . % t. ' .t ,
<br /> 6,2, PGII ) ( )—� - 03 Cu Ft.
<br /> IZ MANI
<br /> III 6 23PG I Regulated Medical Waste, n.o.s., IBR —_ _(C1i0 ) _ _Gal . C;orrugatsd Bw: ( 4 . 32 CuPt
<br /> UN3291 Regulated Medical Waste, n.o.s., Cu Ft.
<br /> 6.21 PGII A 91t 0,k t 9 U I It a Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 6.20 PGII Cu Ft. '
<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 621 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s., aiiinmipff
<br /> 6.2, PGII Cu
<br /> F .
<br /> 3. Generator's Certification : "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/piacarded, and
<br /> are in all respects in proper condition for transport according to applicable International and national governmental regulati
<br /> XPrintaingedNarne AlliiiiiiiVft C lZt-i
<br /> Signature Data � 0 d
<br /> 4. TRANSPOQTER i ADDRESS: V Phone N: ( 20U)
<br /> `} toimicyclC , 1110 . Ell
<br /> Th 'Ity, Is a1 .I fifolligh ` hilaliialit Applicable Permit Numbers:
<br /> 7875 R A Briticiet'ot't'I Rd * T S=f0 S T&A811
<br /> SttzG, idon , CA 95206
<br /> o°C TRANSPORTER CEEMIFICATIONs R ceipt of medical waste as descrIWVob
<br /> Pdnt/rype Name 1 Signature :_!� L — ••••—, Date AA. bfT
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> a Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br /> PdnVType Name Signature Date
<br /> 8. 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 /> PdnUType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 8A. Deal . . — 89. AftemateFacilHy: ❑ We Akemate Facility: 8D. Alternate Facilhy:
<br /> i.-»..r.. Mr,
<br /> - r - f', f G Iii G i , /i+ r: 1l f• . ) la , in . . (incinerator) t _ r'Ic• ; I _ , irn� . (r, 1t cl �� _ ) a . an .a i'�9CA
<br /> riarilr, c:
<br /> 7 :: 75 AU'i . .1 . �+ C� H . Foxboro Drive 2175 E . 26(h St, i 850 DrooldaIw Road IINJE
<br /> � �^,r: I;t;, s, , C:F, p2+aB nlntth alt Lal ; n , U1 Lflt� i 1 Vernon , CPA 00068 F� reolt :�, h(" '? 73u5
<br /> �''`� 2 � i 10 Q22 Orli 9='q - 'ii7i (88�s
<br /> r � ` a moi\-r1=1 � P _ rmiti't . ri
<br /> EAT (ta 1ply4hat I In ve been authorized by the applicable state agency to accept untreated medical wastes and that t have
<br /> i- r eived ccordance with the requirement outlined in that authorization .
<br /> PrinMpe Name Signature Date
<br />
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