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MEDICAL WASTE TRACKING FORM NUMSER
<br /> <,a Stencycle' IN CASE OF EMERGENCY CONTACT: CMEMTREC 14KWQ44300 STANDARD MANIFEST 001 -03.21 -HOCA
<br /> outo it 706 " 0 CUSTOMER NO, 21132 IVINK000DE:4
<br /> I . Generator's Name, Address and Telephone Number
<br /> iEric
<br /> To ; tY DIALYS' ISoD/ VITl '' 20 'IG iii illllllllllilllllillillIllli # lulllliIlIll ! illIll
<br /> 3 12 S 1=ltiRfV NTAVE W80022
<br /> I . 0M Cit K2 .40 . 30110 (209) NMI I t3
<br /> 6053303- 00 .1
<br /> CUSTOMER NUMBER GENERATOR'S REOISTAATION 0
<br /> 2A, DESCRIPTION OF WASTE 2S. CONTAINER TYPE 2��CgqyyNot OF 2D. VOLUME
<br /> 623 PGIIRegulated Medical Waste, n.o.s„ • l L 1 '1 - { L;Iv) Ali__ 1' ld - ( 1" dI1I)_� l Y 1 I ( IiIGIItI ' I aI! ) ; +t Gdl . Tub v _U (; lf !)
<br /> • Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s., ' 113 `21 -( IJIu --___ _ Il, l j - (I ' allt } l "/ 116 C IIliI1 U }" 20 GalffTtilr 2 7 Cult .)
<br /> 6.2, PGII ) ( {` Cu Ft.
<br /> jr F UN329t , Regulated Medical
<br /> FFFF Waste, n.o,s.,
<br /> 62, Psu • • � f ' 1 ' ' t ,
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<br /> WPM
<br /> UN3291 Regulated Medical Waste, n.o.s., lt )_ ' { J . 0/ 0 .
<br /> 6.21 )Gi1 X4a Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n,o,s.,
<br /> Z 6.2, PGII Tilt � ( � IU ) Ui: 1 . Ck:' 1I1IgiaQk1 Dox ( it .32 Gtl Auj 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 Cu FL
<br /> UN3291 Regulated Medical Waste, n,o,s•, Cu Ft.
<br /> UN32911 Regulated Medical Waste, n,o,s.,
<br /> 6.2, PGII Ou
<br /> Ft.
<br /> 3. Generator's Certiflcadont "I hereby declare that the contents of this consignment are fully and aocurately TOTALS 111op . 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 regulatlone
<br /> Naarla ofjDeb
<br /> 4. TRANSPORTER i ADDRESS: Ptwne #:( 209) *70411& A let
<br /> ;; tCl ( Cyc14 , IIID . I' ttis 1s q0I Ituotryit 'Shipiolivelit VApplicable PermitNumbere:
<br /> % 875 R A f3ridUnford Rd . � `iV31/01,r iT• Fl ()
<br /> Stucktoii , CA 95206
<br /> TRANSPORTED..CfRTIFlCATIOhLx pt of medical waste as deac
<br /> Prtnt/Type Name UQ'>,'t- SignatureaFdQ!Z ' 6eDate 21j � tJ
<br /> 6. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> 1
<br /> PdnV ype Name Signature Date
<br /> `n E. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone C
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> Lialm
<br /> �� tie. Altemoft Facility: W. Albmsh Faclihy. $0, Aksmab Facility:
<br /> : , Iris . f r+ S✓C _a'_ fic; . I ? , ii ': . ( ill ill >: CJtia ) w; l _fl '_�1 : �= , iIIC . (�'.Ut : +a �4 +_� t� 4Vdtrhi ! lrj : tii+fl , if P:
<br /> �fIf1R'tt `T ' I , . � 17i. f , 5. 'hi,( h t )rj)J' '7 ] ] �7 '•' , ' hll ) � t+ , i G51� f • ri ul+ Iii i '{;., 1;,x . 711 i iF;1 , � .�'J� Nit� iflip � s3it t . c:l: (_i I CIitiLr r . filLrtl , I.i �' I��IJO fl/ O � , . Jtl :�- '111 t nl8 Z ; Ul l3t - 117 i ; layi ! �3 - ?<I '' 2 U - (] c• _1 !�yoe,,�� s ; i ? r',- vlF' Yrrrili/ 3t; t
<br /> P ' FA'AM that I ha been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> indlce ed a in a rdanoe with the requirement outlined in that authorization .
<br /> Prima ype Name Signature Date
<br /> 0Rill"*M
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