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'. MEDICAL WASTE TRACKING FORM NUMBER
<br /> -•�� Stericycle! IN CASE OF EMERGENCY CONTACT: CHEWMEC 1410111=4244M STANDARD MANIFEST 001 .03.21 •NOCA
<br /> ' Roule 3E: 706 _ CUSTOMER NO. 21132 IL'1 €� RIM0 '10(� A
<br /> I . Generator's Name, Address and Telephone Number
<br /> tT I }l : Eric t i•+uta f > re n
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<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION M
<br /> 2A. DESCRIPTION OF WASTE 28, CONTAINERTYPE 2C. Nos OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n,o,s., 7 t! d- (_, CO A)NERS
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<br /> W UN3291} Regulated Medical Waste, n,o.s„ l+ti ( SIG ) _ _ 321 . r: Di rucj ats= d Box (:1 . �, ? C-001 . 1
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<br /> UN3291 Regulated Medical Waste, n.o.s.,
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<br /> 3. Generator's Certificatlon : "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 all respects In proper condition for transport according to applicable International and national governmental regulations:'0 IX �7
<br /> Print me Na , t Signature Dar
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<br /> 4. TRANSPO ER, 1 ADQQREgS: Phone N: ( 209 ) ."e t 4� ) 1 ` + 1
<br /> `� 11Cyt 1r3 , IIIc . l lit f �1 <� 11F11POLI h Applicable Permit Numbers:
<br /> �C 7 ; 7Z1 R A Hrnitlt it,;f tod f c ;lMINIM
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<br /> o°C a TRANSPORTER FICATIOON :: llReceipt of medical waste as described vs. r I /20�Prinl/lype Name - - QrI G91 Signature M4 1� C '�'"`___— Date � 1
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone C
<br /> N Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> PdnVtype Name Signature Date
<br /> r, 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M:
<br /> kr Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PdnVtype Name Signature Date
<br /> tp 7. DISCREPANCY INDICATION
<br /> " 6A, Designated Facility: 88, Attemste Facility: 8C, Altemato Facility; 80, Altomato Flocliky:
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<br /> EATMENT FACILITY: I certify that I h ve been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> t- r efved bove�tgr�y�astes in a ordance with the requirement outlined In that authorization .
<br /> Signature Date
<br /> I
<br /> ORIOINAL
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