|
MEMCAL WASTE TRACKING FARM NUMBER
<br /> r 9e� Ste �' � cyde¢ IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 00-4249300 STANDARD MANIFEST 001 .03.21 •N0CA
<br /> CUSTOMER N0, 21132
<br /> 1 . Generator's Name, Address and Telephone 8Mb,;81`, 706 .3 [UIM0011303
<br /> TOKA`i' DtAI.YStS-JD!>:4/ tTA #?01G
<br /> 312 ,13 FAIRMON T AVE 12/2/2022
<br /> LOCI . CA 95240 - 3640 1209 3GM41
<br /> CUSTOMER NUM9ER GENERATOR'S RQOMTR YM
<br /> 2A, DESCRIPTION OF WA %:'a E I CONTAINER TYPE 2C. Not OF 20. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., CONTAINERS
<br /> 6,2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s., Telflsio ) TF "1i1 - (P•ath)- �T1` 1a • QnCineraG=)� _ 44Cial . Tub (5acuft)
<br /> Cu Ft.
<br /> p 623 PGII Regulated Medical Waste, n,o.s„ 1 L321 (Bio ) TF15- (F'�th }__�T1` 1Ch (Cherna)„�_,_ '20 Goal . Tub ( 2 , ' c:'uft . ) Cu Ft.
<br /> Q UN3291 Regulated Medical Waste, 1' GAO- (Elo ) 11� } [�.(Chetiio) TWC1 (lrlcin Catr) 37 Gal . Tu ( 11 ,0 Cuft. )
<br /> 6.2, PGII Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s., VVEt c1-( Bio )• _ U I IQ iarllo ) t �( !'�- ( resCril 3 tea .
<br /> tZ 6.2, PGII . Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s,, l • 1'fo _ baa . V orru dater box °I . oz . 0 r .
<br /> 6.2, PGI) Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n,o,s.,
<br /> 6.21 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 /> 6,21 PGII L u Ft.
<br /> 3, Generator's Certification: "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 classifted, packaged, marked and labelled/placarded, and
<br /> are In all respects in proper condition for transport according to applicable international and national governmental regulations" hh
<br /> PrIntodt6riped Name turf t " j
<br /> Q 4. TRANSPORYER 1 ADDRESS:Oor Phone N:
<br /> f�; t'i�;rcla , It1c _ This is n 'litroll�it �;itita+n�ltt ApplicaaJeWrnit�N' �� 1 �1
<br /> 4 N 707 �T R A Bridgetord Rde T`/r , j� ;� 0
<br /> r a %N 'a q TRAI FICReceipt of medical waste as described . '
<br /> ~C dodg, PW,
<br /> PrinVType Nama Okt / Signature . L/s'y� /n Date
<br /> 5, INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> NW
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/T)ype Name Signature Date
<br /> 6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Rhone N:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Ir — PrinMpe Name Signature Date
<br /> 7, DISCREPANCY INDICATION
<br /> !- 9A. Desipneted Facility: Alternate Facility: BC. Alternate Feclllty: OD, Alternate Faculty:
<br /> J a rrta, � Y itI YAN' . ) - o ricyMe , Inc. (Incinerator) Stericycle , Inc. (,� :atodave ) .oventa kiarion , Inc
<br /> U 7075 f; J� G� AWI) 9C N . Fr�sior+� Grive ;!77F >; . 25th St, " r -, �
<br /> C 0 ., 0 Br - oWJ .k - RoaD NE
<br /> °- sto0fpn , CA 95205 = Id th SqBlt Lala , UT 81054 Vernon , C A 90050 3ruel%�, C1F X17305
<br /> z :20 ! lie" (� 2�Z� (3 i ),�•3?- 1179 (868)733-74 '72 5G5}3 _ ' 0p90
<br /> � i`�/ C'��:�OfY '' 8r. ABI.!=�.- SE; ��.rr��ity.' 3rSk
<br /> ¢ TFlu
<br /> ATME FACILI t I hav been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> I— rec Ived th�� rdance with the requirement outlined In that authorization .
<br /> , 4 Print/Typs Name Signature Date
<br /> d-
<br /> O '
<br /> O •
<br /> ORIGINAL
<br />
|