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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Sri* Stericycie' IN CASE OF EMERGENCY CONTACT: CHEMTREC 15800 4244300 s7ANDARD MANIFEST oot os-21 -NDCA
<br /> Ro y
<br /> CUSTOMER NO, 21132
<br /> 11 , Generator's Name, Address and Telephone Number
<br /> ic Crowley
<br /> TOKA` DIA YJSISrDAN? ITA 742016
<br /> 3 `I2' SFAII rVIONTAVE '11 /22/2022
<br /> LOCI , CA 95240" 38*40 (2D9) 369- 5410
<br /> CUSTOMER NumsER 605330MI0 GENERATOR'S REGISTRATION If
<br /> 10011
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO, OF 20, VOLUME
<br /> UN3291 , Regulated Medical Waste, n.o.s., CONTAINERS
<br /> 6.2, PGII T B14 ( B'sa ) T P144Path) TYladincinerate 44 Gal . Tub f' ' C�lCuftl Cu Ft,
<br /> UN3291 , Regulated Medical Waste, n,o•s., Q 21l S; �I i Iib 7 1�uft. Cu Ft.
<br /> 6.2, PGII TP21 (Gio TP 1 a (Pani T`( i {ia{, rr is
<br /> C 6236,► Regulaied Medical Waste, n,o.s., T !849- Bio TY49- Cherna TI4W- (ITICirteratS) 37 Gat . Tu f4 J C-0 .1 Cu Ft.
<br /> QUN3291 Regulated Medical Waste, n.o.s., Gal . J
<br /> cc 6.2, PGII 0J8421-( Bio) G N4 ;' (Chema)- 1 ,_ _ s V „43- (Phan•rr ) 43 �al . Tu ( 5 .7 uu Cu Ft.
<br /> W 61�3p9G11I Regulated Medical Waste, n ,o.s„ i/ R
<br /> Corrugated eox (4 .32 Cuft .) Cu Ft.
<br /> UN3291 ,
<br /> Regulated Medical Waste, n.o.s• , 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 Ft.
<br /> UN3291 , Regulated Medical Waste, n.o•s.,
<br /> 6.2, PGII Ou Ft.
<br /> 3. Generator's Cer1iftertlon: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► 5 a 3 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 appllcabie international and national governmental regulations'
<br /> ^ 4
<br /> PdntKVIVW Name t ld 3f S natureDatta Z7/
<br /> 1111M I
<br /> 4. TRANSP Phone :E' 56YI t
<br /> L This tS a Tlit4iJL� Ii i �ll�?Irl . tit Applicable Per Nu �
<br /> 7075 R A Bildge.ford Rd . r`� �t ��`��k, il
<br /> Stockton , GA 95206
<br /> a TRANSPORTER C IFICATION: Receipt of medical waste as describe ova.
<br /> PrinVType Name iR - SignatureLi�:l�IZfID' yL `►-x— Date
<br /> S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone 00 ' . 0 pit
<br /> too W
<br /> N 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 M:
<br /> Applicable Permit Numberw
<br /> '!q INTERMEDIATE HANDLER i TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> i
<br /> PrintJType Name Signature Date
<br /> I 7. DISCREPANCY INDICATION
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<br /> I $�. lrf�t t1lto,i8tJ2) !t t , • . , f�iffhe-iner3tor) to. m. thee, 1'utoolave) Unr VolIFtlmiimcv
<br /> 7076R A QriC Pi 90 fel , Foxboro Briae 1775 E . 26th St 4850 Bnaoklcke Road NE
<br /> NINNIP E a St �cs;tu�f f ED North Galt L2he , UT 84 054 Vernon , CA 90068 Br., olcs, OR 1.17306
<br /> a- 209 294 T981] i 83(i 1171 (868)783- 74N 50a 303. 8n80
<br /> u ""VV 2 2 2022 -aao�l�,- P.-rl 'r,it 'N' 3364
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<br /> P11 TREATMENT.411r01111111119 A - rtify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have ;
<br /> I N received the above indicated wastes in accordance with the requirement outlined in that authorization .
<br /> PrinVType Name Signature Data
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<br /> UHIUINAL
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