|
MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stericycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -8OD4249300 STANDARD MANIFEST 00103.21 -N0CA
<br /> Route * 703 _9 CUSTOMER NO, 21132 MD7K00 'I B52
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATDI Eric DAVIy 11111111 oil 11111111111111111111111111111111111
<br /> TQKAYDIALY�f �-f�AVITA #2016
<br /> 312 S FAIRMONT AVE 112412023
<br /> LODI , CA 95240-3840 (209) 369-5418
<br /> I
<br /> 6053303- 001
<br /> CUSTOMER NumsER GENERATWs ReotmAnoN K
<br /> 2A, DESCRIPTION OF WASTE 28, CONTAINER TYPE 2C. Nov OF 21). VOLUME
<br /> UN3291 Regulated Medical Waste, n.o;s., TH43(8io)610 PGH .q.TP4u(Pa) TC43(Ch) TX43 (Ph) � j r� S Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.s., to 1 al ub(4 1 �
<br /> 6,21 PGII Cu Ft.
<br /> CC UN3291 , Regulated Medical Waste, n,o.s., K R ( 5o) RX ( harm) Corrugated Sox (4 .3)
<br /> 0 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s., RX� AlJQT Gasketed Sharp Cont, CUP)
<br /> tY 6.2, PGii Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s., a5 2 p Z arp on . U
<br /> W 6.2, PGIf Cu Ft.
<br /> Vr UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII I 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 /> 6.2, PGII a Cy
<br /> F
<br /> it
<br /> 3. Generator's Certification; "I hereby declare that the contents of this consignment are fully and aocurately TOTALS • (� 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 co clition for transport aocording to applicable International and national governmental regal ns'
<br /> C P Name \ A V6
<br /> ds; welginau"
<br /> 44 TRANSP y pi1a ThWe ie a Through Shlpm Phone #:
<br /> 7875 R A Bddgeford Rd . Applicable Per�cTn60
<br /> Stockton , CA 95206
<br /> En a TRANSPORTER C FICATIO ipt of medical waste as described �,1
<br /> Prin �, y ( � signature w"� � �! Vt 1-2'q)'0L -Vt/lype Name ate
<br /> S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone No
<br /> a � Applicable Permit Numbers:
<br /> 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 Of
<br /> CC
<br /> ' Applicable Permit Numbers:
<br /> tu
<br /> ZINTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrinV ype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> ve F�oll oc ave a e sal ,
<br /> 7878 RAjn - 51 Shelton t7rive 2775 E . 28th St, 850 Brooklake Road (JE
<br /> St9'eldon , ME Dillster1 Cr195023 Vernon , CA 90058 rooks, OR 97305
<br /> u. (209j294-7114 88)783-7422 (888)783- 7422 505)38 ? 8890
<br /> W TS TST� 2 5 2023 L, c T-s " �r1�it # say
<br /> JUTNEW ><AtAj that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> h- recely sten i accordance with the requirement outlined in that authorization.
<br /> CD Print/Type Name Signature Date
<br /> CD
<br /> CD
<br /> ORIGINAL
<br />
|