|
MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stericycle° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -6110-424-9300 STANDARD MANIFEST 0ot •o3.21 •NOCA
<br /> ,., t ; t .1 ;, .I Sol 0 - 1 CUSTOMER N0. 21132 I .'i1) "1"1 . 000:o', DL
<br /> I . Generator's Name, Address and Telephone Number + {{ `
<br /> l'4W l._ ric• i_ lotor' 1SU �.f Lj � � ;I " s1c � r • cr :r (1 � ., , j l .i i� e : I , : . .i , i . �) a { � pv + : :
<br /> Di , •. LY i " Eiji III i- , :. ;'.t) i � . 11 , . . :: � r : E3 ,. 1 : 1313, . . 11 . _ i , . � 11 „ i � i . . , .. { .
<br /> FilVi �. rfti", J � : iia/7 () .''
<br /> l~ Cri il , �:; 1i , ;> : {' urirj IS
<br /> CUSTOMER NUMaER GENERATOR'S REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 2B, CONTAINER TYPE 2C. NO* OF 2D, VOLUME
<br /> UN3291 Regulated Medical Waste, n,o,s„ 1 ; ) rI r ILIr1 i ' • I Ohl , tI� JCONTAIINE
<br /> 6.2, PGII g : C ( i . ; o1M... ; t ' i ; r= :, . "t ) � _ i r • � 1._�— )
<br /> > Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.os„ iSol ' ` ' rG :'. i:.1 Tub ( Ift . )� T6.2, PGII c
<br /> Cu Ft. Sol
<br /> O " . lir623RegulatedMedicalWaste, n,os., i pGi1r : i _ , {ti
<br /> Cu Ft.
<br /> UN3291Regulated Medical Waste, n,os„ ' ; : -� i. i ' _ •Y _ .., CS' , ' l :; -('�'ii1lli 'r ! . • ._. , r't=t �- ( F '} tstt'rll_. .__ . =1 � '�; 31 lult .i „ f"t_til , j
<br /> 6.2, PGII Cu Ft.
<br /> W UN3291 , Regulated Medical Waste, n,o,s., in1 - liriZ 692, Poll ' ti -•
<br /> i
<br /> Cu FI.
<br /> O UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.21 PGII ( "l/j
<br /> .3 C A r 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 FL
<br /> UN3291 Regulated Medical Waste, n,o,s.,
<br /> 6.2, PGII Cut Ft.
<br /> 3. Generator's Certification* of 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 classified, packaged, marked and labelled/piacarded, and
<br /> are in all respects in proper condition for transport according to applicable International and national governmental regulations"
<br /> Printed/Typed Name f„/~ Sign Date
<br /> 4. TRANSPORTER IADDRESS: PhoneN : ( �'. tl '.) ) ;_' '• t - j t I :r
<br /> U
<br /> � W� i.�1�r47' '5It `!, O:+vo ,I•t1t1t1r;lr. a If ,, t• iitt- lrt .`.AI ? til :%n
<br /> tti Applicable Permit Numbers:
<br /> �! �,I�j ,.; •I • If1 !
<br /> SWISS
<br /> S N _ l4tLiiiGti tsl�. I ._ tJt)
<br /> CC TRANSPORTER-URTIFICATIOP& Receipt of medical waste as described a e.
<br /> PrinUTypeName Vd�L d � ttrol Signature
<br /> Slow 54 INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone H:
<br /> Applicable Permit Numbers
<br /> El INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Print/Type Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M:
<br /> w Applicable Permit Numbers:
<br /> Z = INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> fE - Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> I
<br /> 6A. Designated Facility: 8B. Alternate Facility: [� 6C, Altemete Facility: SD. Alternate Facility:
<br /> F r I ^ ; , 1 , t . 1 • - i fir : I_ , ; u '
<br /> _ : 1' Ir IIrIC , �I ? i ;� i:' i ) Ctrl -� tl . { : Il, . ( r I ,' , t' ) Cva , ,, T. :zi fr . . rr_
<br /> Q , . ; . , ,• .: . r; .,MAYRA ihh, , „ _ t -
<br /> LL
<br /> F r 1 t • ? ' i J' i ! : ;{ �'•' `� 'i' ! �'' i s }r ! Cr' =, t . , . ' ; r _ lj :
<br /> HERNANDEZ ' `-
<br /> it � : L '_I I - r l r ': III I '.I itJ - 11 �' i {� �.'t-< Ira� 3 • r '11 .� ( Jl: 1j ; J::. (I IS' J
<br /> a
<br /> $ ` r' - . 1 - :` `I JAN Z 9 2022 - . L' . r- r• rIS , -A :. 1l :,
<br /> W REATMENT FACILITY: I certify that I havi i been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F- ceived the above indicated wastes in acci irdance with the requirement outlined in that authorization ,
<br /> moa""""' `r
<br /> rinVType Name s Signature Dale
<br /> {
<br /> ORIGINAL. `
<br />
|