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MEDICAL WASTE TRACKING FORM NUMBER
<br /> ��� St@PK�/CI@� Mi CASE of EMEROANCY CONTACT: CHEMTREC 14100�4244M STANDARD MANIFEST 001 .03.21 %NOCA
<br /> � " 7 " CUSTOMER NO, 21132
<br /> 1 . Generator's Name, Address and Telephone N&a0i*r#: 7063 -5 MDTKaa 14R6
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<br /> TaKAY DJAL1' al ` DAVI7A
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<br /> 3 '12 S FAIRMONTAVI* I 't /1u/Za22
<br /> LODI , CA 9512440m3840 (209) 3169-5418
<br /> HOME
<br /> Cusromen Nu►roen , ClemATm,s Raowm tm N
<br /> WIND
<br /> 2A. DESCRIPTION OF WASTE 21114 CONTAINER TYPE 2C. M06 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., ' i `' " v._ ' f ' l "1 t' u u )
<br /> 6.2, PGII Cu F6
<br /> IM UN3291 Regulated Medical Waste, n.o.s., ' ' ` ' - 1-- - - ' �'� ' ' ' "-' — - - t
<br /> p 6,2, PGII Cu Ft.
<br /> I' UN3291 Regulated Medical Waste, n.o.s., ' ' s at- tin n n > nv �c r as . . c U
<br /> 6.2, PGiiPPI Cu Ft,
<br /> W UN3291 Regulated Medical Waste, n.o.s.,
<br /> LU 6.2, PGIi r, _ I Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.2, PGii Cu Ft,
<br /> UN3291 , Regulated MadIW Waste, n.o.s.,
<br /> 6.21 PGI( Cu FL
<br /> UN3291 Regulated Medical Waste, n.o,s„
<br /> 642, PGI) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s.,
<br /> 6.2, PGII Cu Fl.
<br /> 3. Generator's Cono 'I hereby declare that the oorltente of this consignment are fully and accurately TOTALS Poo • Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placardad, and
<br /> are In all respects In proper cAdiftion for tra according to applicable intemational and national governme u
<br /> NarrN n - Dale ZL"
<br /> 4, TRANSPdRTER f ADDRESS: Phone N:
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<br /> � a ,� a • 71 .1 r1
<br /> Till i iS a TI1"$IV lgII ". 111I)iylRlit Applirade �rmh �umbens:
<br /> 7375 R A DI•idgef{? rd Rd . TS/OST- 81
<br /> Slociitoll , CA 95206
<br /> TRANSPORTER CE FICATION ecelpt of medical waste as described 'Go/y,,�e
<br /> PdnVlype Name t1� ` tl � Signature -- !��Z / n Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; phone M:
<br /> `V Applicable Permit Numbers:
<br /> INTERIIAEDIATS HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical weals as described shove,
<br />� PrinUlype Name Signature Dais
<br /> M 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone C
<br /> App(kabie Permit Numbers:
<br /> INTERMEDIATFE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br /> PrinUType Name Signature Date
<br />[ 7. DISCREPANCY INDICATION
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<br /> DWgneted FOcIINyr CTSS. Atfsfrlsss Fedllty: 11C. Aksmsb FWNtyr sD, Ahwr*W r FedItty:
<br /> f Stericycie , Ino. (Autocla . ) Sterivide , Inc. (Incin_worator) St~rricy_le , Iric. (Vutoolcve) C'cwac'ita tftarion , Inc
<br /> V 7076 %k4, t,mi (3AkFA 013 N . I~oxooro i~ ri �j _ 2,75 C , 2r,th St, 4850 Drooklake Road Nil
<br /> LL StcicKton , qui &LhVED Mottil S:ft L31ce , UTE! 054 Vernon , Ci, 9QN3 8moits, OR 97305
<br /> ('t?'�)2'?4- 71 .14 ("11i ) '9W1171 86 75V- 7 # 22 F ` ^r
<br /> .. a { ) ( �U � lc � 3 tl:3QCJ
<br /> W -t CICOST OV 212022 cn "4WJA"- 86 J ?la;
<br /> TREATMENT F ClrY•,�__��eertify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F received the AW*Wft a tea in accordance with the requirement outlined In that authorization.
<br /> E, Pdnt/lype Name Signature Date
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