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MEDICAL WASTE TRACKING FORM NUMBER
<br /> io Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -800 4249300 STANDARD MANIFEST cot os•21 •NocA
<br /> CUSTOMER No, 21132
<br /> 1 . Generator's Name, Address and Telephone WNW 1 CJ ;5 IVILI I FFGU I bAZ
<br /> TOFtA<< C} } ALYS} _ LtAV } TA01I MUM
<br /> 312 S FA } RIVICkI AVE 1216/2022
<br /> l. OD]" CA 95240-WO (209) 31:16M4- 10
<br /> CUSTOMER NUMBER {' r"j ', 3 GENERAMIRrs REGI mr#oN N
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C, Nov OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., CONTAINERS
<br /> 6.2, PGII a . in • _ - -• t , r Cu Ftp
<br /> UN3291 Regulated Medical Waste, n•o,s„
<br /> 662, PGII 711 t z i , in . . Cu Ft,
<br /> M UN3291 Regulated Medical Waste, n,o,s., - �' - - - • _ • '
<br /> & 6.21 PGIIs n• ) - v d r. ee . > > r _ 7 _ r lei r t Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s., '� y _ ' F141` ` ' " - !
<br /> 6.2, PGI) rrrro a / c: . � r•l4r r•r. - r v 7 r o r• _. „ t- F 7r , r: t a Cu FL
<br /> W UN329t Regulated Medical Waste, n,o.s., '
<br /> „ _ � - - -
<br /> 1JI
<br /> 2 6.2, PGI) nVIP _ ( Pin5 r• nr• r , , - t r? .,p f ^ 7 r r 1 Cu Ft,
<br /> C�3 UN3291 , Regulated Medical Waste, .o,s.,
<br /> 6,2, PGII 'coY 0 t a • Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.S.,
<br /> 6.29 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, no.s.,
<br /> 62, PGII Cu Fit
<br /> UN3291 Regulated Medical Waste, n.o.s. ,
<br /> 642, PGi) Cu Ft,
<br /> 3. Generator's Certification; "I hereby declare that the contents of this consignment are fully and accurately TOTALS110P %77. Cu Fte
<br /> described above by the proper shipping name, and are classified, packaged, marked and laballed/placarded, and
<br /> are in all respects in proper condition for transport according to applicable international and national governmental r ui
<br /> Pit Name DOW
<br /> CTRANSPORTER 1 ADDRESS: Phone ff 209) • 294 ? 114
<br /> tericycle , ( t1L' . This t5 a T} I'rOL11 I}i Shipment Applicable Permit Numbera;
<br /> 7875 R A Bridgetford i- d * TS/OST 0
<br /> R StbCRI0111 CA 952106
<br /> Z TRANSPORTER CEICATION: Ne
<br /> t of medical waste as deacrt
<br /> Prinl/Type Name 1J � ► t 0 Signature 45 IV, �< V Data 1 41 0al2d.GG-
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> N � Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> PdnUiype Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> as rr Applicable Permit Numbers:
<br /> _ INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> x
<br /> - PrinUrype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> WO
<br /> f R!Uve
<br /> 88, Atbmate Facility: ltC. Att�rnsta FaCliky; 6D, Albmatrr Facility:
<br /> > ) ,tarl(wole , 1110. (Incinerator) Stericycle , Irlc. (Alitodave) =-avanta (Marion , Inodsaerord Rd , 0 N , {=oxboro Dm/e 2776 F 28th St, 1880 Broni;lake Road �!C
<br /> 9 32022 cru; alt Lui;? UT54054 Vernon , CA 90055 3rochs, OR 97305
<br /> }— T� l . :0 (8L1E )793-7x22 sOFll�i�d ? (3890
<br /> LU
<br /> 80 4480A #1364
<br /> W � �
<br /> ve been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> II— received the above Indicated wastes 1n accordance with the requirement outlined in that authorization ,
<br /> Lr) PdnUrype Name Signature Dale
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<br /> - - - - - -- - - — -- - - - - - - ORIGINAL - -- --- - - - - -
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