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MEDICAL WASTE TRACKING FORM NUMBER
<br /> i� Ster icycie` IN CASE OF EMERGENCY CONTACT: CHEMTREC 1800 4249380
<br /> STANDARD MANIFEST OOf o3.21 •NOCA
<br /> RCjt,tira 4: 703 - 17 CUSTOMER N0. 21132 MDTKO0419PY
<br /> 1 . Generator's Name, Address and Telephone Number II ##D11�t_`I' '� l � - Df
<br /> ATDI Lair.. E..• t'O +l :llr:
<br /> TQi �1 111111UH111111101,15111 { III EI1
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<br /> 312 S E"AI3;IAONTAVE 11 /10/202. 3
<br /> LODI , C A95240-3 40 ( 205) 369••5418
<br /> CUSTOMER NtJM6ER 6 05330 M 01 GENERATOR•a REGISTRATION
<br /> 2A. DESCRIPTION OF WASTE 213. CONTAINER TYPE 2C. NO. OF 20. VOLUME
<br /> UN3291 Regulated Medical Waste, n,o.s., ,i , • v, ^
<br /> CONTAINERS
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<br /> 623PGfRegulated Medical Waste, n.o.s., T11c I ( Cln )_ w _ _ TP3 -1 (Pa )__ _TC: 3 '1 (C' h ) �_ _ TY.3i (Pi1 )_,_„ 310Z1IT �. ] ( fV
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<br /> 623PGIfRegulated MedlcalWaste, n,o.s., KR ( 1310 ) RX Thartll ) corillgated Box ( 4 . 3 ) Cu Ft.
<br /> o UN3291 Regulated Medical Waste, n,o.s.,
<br /> at 6.20PGd RA 10.61 OTGaEketed :harp Cont . ( C'ui=t ) Cu Ft,
<br /> W UN3291 Regulated Medical Waste, n.o.s., �•�I i� T w aSkEteu lar C; ont . GuFt
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<br /> W UN3291 Regulated Medical Waste, n,o.s., Cu Ft.
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<br /> UN3291 Regulated Medical Waste, n,o.s.,
<br /> 6.2, PGI! t Cu Ft.
<br /> UN329i Regulated Medical Waste, n,a,s.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s.,
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<br /> 3. Generator's Certification: W hereby declare that the contents of this consignment are fully and accurately TOTALS ► 1 O Qr,, ` Cu Ftt
<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 acc W g to applicable International and national governmental regulations"
<br /> 1NZ.� �' 23
<br /> Prir>t Name Signature Date
<br /> 4. TRANSPORTER 1 ADDRESS:Ix tf: ( 709 ) 294_71114
<br /> stericycle ? 1llc . This is 9 Thru" ttyll *311illtllellt App! ble Permit Numbers:
<br /> Q7075 R A Bridgeoford Rd . TS/OST 80
<br /> am Slocklon ? CA 05206
<br /> a TRANSPORTS FICATION : Receipt of medical waste as dowel
<br /> �` � Ito g
<br /> PrinUtype Name F� {'�- Cott,Cott, Signature . G� — d �
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone C
<br /> N
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Pr!nVT'ype Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M:
<br /> cc Applicabie Permit Numbers;
<br /> a INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION : Receipt of adical waste as described above.
<br /> PdnVType Name Signature Date
<br /> T. DISCREPANCY INDICATION
<br /> I8A. Dalyrurbd Facility* 88. Altemtta Facllky: 8C. AltamsU Faclllty: 8D. Altamato Facility:
<br /> I
<br /> � tericycyOSE .SILKA. i �ve) Steri,y:t ,IIS , li•,e . (Indneratr1r) 3terfcycl_ , In1c . (AUtcclsve ) ': o,..anta F12rion , inc
<br /> 7E75 R .W9, YE19i .d . 90 N . Forboro DrikIe 27 .16 En 26Lh St, 48," Eirooldake Road NE
<br /> U' wcl•.tor, 4 C Is% Q 5 2 0 6 Nort', Sall Lake . LIT 040511 Vernon , Cf? 90053 Drools, OR 9 '1305
<br /> ? I]p 1' A I l n ,w,Ay ' 131 rlrF 1 i71 ( 86 °^- 4 22 F ^ A^ 4Q
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<br /> •]-�i0�"f= �i3 8tt-�ll •�%.+•: -46 Perr�itranf
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<br /> TREATMENTnY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> i
<br /> received the above indicated wastes in accordance with the requirement outlined In that authorization .
<br /> Pr1nVType Name Signature Date
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<br /> - - -ORIGINAL
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