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MEDICAL WASTE TRACKING FORM NUMBER <br /> of., Stericycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 148110.4244M STANDARD MANIFEST 001 -03.21 •N0CA • <br /> R01.110 #: 706 4 CUSTOMER NO. 21132 MDTKOD141 X <br /> 1 . Generator's Name, Address and Telephone Number ff � <br /> ATDI Eric l. r y <br /> �rai�,�►�Y �IftLYS{ S -UANJI�� ► T/4 744'2D16 <br /> 31 .? S FAIRiUI0 ITAVE 11 /11 /2022 <br /> LODIt Lid 552110-3840 (209) 365- 5418 <br /> 605330401 <br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION M <br /> 2A. DESCRIPTION OF WASTE 2B4 CONTAINER TYPE 2C. 140o OF 2D. VOLUME <br /> UN3291 Regulated Medical Waste, n.o.s„ TE 1 (6iD) I � '1 �i-(Pwt}i) _ iYI � (Ir, cin rate) 44 Gal . Tub ( 3 .W. mERS <br /> 6.2, PGII Cu Ft. <br /> UN3291 Regulated Medical Waste, n.o,s., ;' � ( ' ID ) i 7 ,7 ( do i ).^_ i 9 - to 1pIt1D) cid . u 71 . <br /> 6.2, PGIi Cu Ft , <br /> O <br /> n <br /> UN3291 Regulated Medical Waste, .o.s., I HZ rel- ( 'ID ) tr Y4 '- tern5 ( ncinerh e)._.:� cis . ! s, Cu . <br /> 6.21 PGI) Cu Ft. <br /> a UN3291 Regulated Medical Waste, n.o,s., <br /> It 6.2, PGIi 3 • Cu Ft. <br /> W UN3291 Regulated Medical Waste, n.o.s., X t 1 � !j • Culluuttri BOX ! 1t z `— <br /> tultl <br /> Z 6.21 PGII Cu Ft, <br /> UN3291 Regulated Medical Waste, n.m., <br /> 62) 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 /> 6.2, PGII 4 Cu FL <br /> UN3291 , Regulated Medical Waste, n.o.s., <br /> 6.2, PGII Cu Ft. <br /> 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► Cu Ftt <br /> described above by the proper shipping name, and are claselfied, 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 /> PdrftdqVpW Nom <br /> » 6 / <br /> 4. TRANSPOPOWPXIMMEMP - TNG is a T{? OLIgh Fi imiient Phase C <br /> °C 1375 R A Brldgeford Ref . Applicable PermkSw St7 . <br /> Stockton ) CA 95206 <br /> a 1T3ANSPORTER.QFiCATIO �Jegelptof medical waste as deacxi <br /> PrintfType Name ( Signature Date <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 /> Print/Type Name Signature Date <br /> 6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: 4 Phone N: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Print/Typs Name Signature Date <br /> 7. DISCREPANCY INDICATION <br /> riatiny - ' LjtyAa �" hGroriv 2 fi • l t t, y � {! Elrooltla {c :oad h!E <br /> a <br /> Stockton , 1VISE I Grth Salt Lake , UT 84054 Vernon , CM 90050 BrookE, OR 97305 <br /> LL # (20 )294-A O I,AVEU ( •01 )9'38- 1171 (808)7834422 (505) ?93 0890 <br /> Ta," QST 00 448/J.A-36 Pert rA P 364 <br /> IU <br /> NOV 14 2422 <br /> T EATMFp FACIL : I c that I h e been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> cc <br /> I F r ived re In a rdance with the requirement outlined in that authorization . <br /> PrinVType Name Signature Date <br /> I _ <br />{ <br /> I <br /> I <br />