|
MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stericycle` IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -8004249300 STANDARD MANIFEST 001 .03.21-NOCA
<br /> CUSTOMER N0. 21132
<br /> 1 . Generator's Name, Address and Telephone uwr ' Y86y '
<br /> DJAL fICt IDAVItf Ill f Ali ! ( I l II I I 1 1 111
<br /> TOKItY Gl �tL.l'S! r - D/-t�11T11 s= i €a
<br /> 3412 S FAIFtMC+NT AVE 112/3012022
<br /> L60II , CA 95240w* 3840 ( 209) 369-5418
<br /> CusToman Numem 605 3303 001 GENERATOR'S R900MATION N
<br /> 2A, DESCRIPTION OF WASTE 2B, CONTAINER TYPE 2C. NO. OF 2D, VOLUME
<br /> UN3291 Regulated Medical Waste; n,o,s., CONTAIN S
<br /> 62, PGI! Tt ► 1 :'fP,inl TF't1 ? fPal �t :(t': hl `��i�:fP �l I :��, af iifif i ,��%7 cu Ft.
<br /> UN3291 Regulated Medical Waste, nm.s.,
<br /> 62, PGII TH3 �1leliol TF'31fF 'a T�' 311�_h TY. 3 ifP!� t 3 { C7 �1 T�� • 2 cu Ft.
<br /> CC 6UN32291 Regulated Medical Waste, n.o,s.,
<br /> O I\ R (enol RX I' Pharion) Corruc aced Box f4 . 3 Cu Ft.
<br /> 62, P�Ii 91 Regulated Medical Waste, n.o.s„ R x GALIGT QFis caked Sharp Cont . CUFt Cu Ft,
<br /> W UN3291 Regulated Medical Waste,
<br /> 1Z 6.2, PGII SH GALIOT Gasketed Sharp Cont . { CuFt ) Cu Ft
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGIi Cu Ft,
<br /> 1JN3291 Regulated Medical Waste, mo.s.,
<br /> 6.2, PGI! Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s„
<br /> 6.2, PGI1 Cu Ft.
<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 ► 3 v 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"
<br /> PdntodTyped Name AwS tura Dats
<br /> 46TRANSPORTER 1 A DRESS: Phone t(; I ) Z 4 - ' ' 1 '
<br /> Sala"; 1' cyc C , Inc . Thibt i5 I ThI't1Ugh Shipment ent Applicable Pe[ 11,N tubera.
<br /> 7c, 76 R A Bridget rd Rct �;:,l TL,. t - nil
<br /> Sloc % lD1'1 , CA 95206
<br /> a � TRANSPORTERXfERTIFICATION: ecaipt of medical waste as described ahave, (� t �) Lwka
<br /> PrintlType Name Wt1 �� Signature Date L !✓
<br /> �, 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone M:
<br /> a � Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> PdnVrype Name Signature Date
<br /> MENNEN
<br /> 6. 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 /> PrinVType Name Signature Date
<br /> T. DISCREPANCY INDICATION
<br /> i
<br /> ��zliGf X13 , irFiUiCln3r�tOr) 'rtL11" "�i�� ( riI: 1nGivG' IwV� ) _ - /941 iv e � u� 11aG1I :
<br /> 7976 iA .' - A
<br /> t`�d , 90 fk! . F �urooro Drive 2777 R , 26th `o+ , �16u Crc,okli?ke Road (\IF
<br /> a t,ri'.tanA qq or4wr 2wlt Lake , UT 84064 V, jmcn , CA 900663 3rooks, OR 9730 .5
<br /> LL � (?09)11? ?-7114 (f 01 )933 1171 (966)78344 " 505)393-OS64
<br /> 490 a J AI 3l� til rJf\- 38 errr1i0 3x34
<br /> $
<br /> �'
<br /> TMENV166fiW: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> r.03, Te�6ed the above Indicated wastes In accordance with the requirement outlined In that authorization.
<br /> Printlfype Name Signature Date
<br /> ORiGINAL
<br />
|