|
MEDICAL WASTE TRACKING FORM NUMBER
<br /> i0 Sterlcycle` IN CASF*1&k&ENcc70&N1A7bT: CHEMTREC 1 -600.424.9300 MDA8 wl2 r 001 .03.21 -LACCA
<br /> CUSTOMER NO, 21132
<br /> 1 . Gsnera*Ts7'Naff1jg1Mtawjmpd Telephone Numbsr
<br /> TOKAY DIALY5I5�DAViTA IZU16
<br /> 312 S EAIRMONTAVE 2/4/2022
<br /> LiDDi , CA95240-3840 ( 209) 389-5410
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br /> 2D. VOLUME
<br /> 2A, DESCRIPTION OF WASTE 2 1 514 -(Blo ) TP14-( Path ) CON" 7Pri lneratej 44 Gal. Tub gct5'r1tA�JE
<br /> UN3291 Regulated Medical Waste, n.o.s„
<br /> e.2, PGII (. Cu FL
<br /> UN3291 Regulated Medical Waste, n,o,s, , �"u
<br /> 6.2, PGII TPA QJRjn )===jY4f' i 4 Cu Ft.
<br /> X UN3291 Regulated Medical Waste, n,o,s,,
<br /> O621 PGII 9 C` 1 r Cu Ft.
<br /> Q UN3291 Regulated Medical Waste, n.o.s„
<br /> 6.2, PGI) 4 ral romug ox o Q Ift Cu Ft.
<br /> W UN3291 , Regulated Medical Waste, n.o.s.,
<br /> IZ 6.2, PGII Cu Ft,
<br /> 5 UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Ft.
<br /> UN329i Regulated Medical Waste, n.o,s.,
<br /> 8.2, PGII Cu Ft. i
<br /> UN3291 Regulated Medical Waste, n ,o.s., Cu Ft.
<br /> 6.2, PGII
<br /> UN329i , Regulated Medical Waste, n,o.s,, Cu FI
<br /> 6,2, PGII
<br /> 3. Generator's Cartificatlom "I hereby declare that the contents of this consignment are fully and accurately TOTALS )10 Cu Ft4
<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 dition for transport according to applicable International and national governmental regulations"
<br /> Printed/Typed Name Signature v
<br /> CTRAN904MYRIOW9This Is a Through Shipment one M.
<br /> w 7075 R A Bilidgoford Rd . plicable PerrnT&Q*9 80
<br /> a c Stockton , CA 95206
<br /> CL
<br /> N
<br /> a < TRANSPORTER CE CATION : Receipt of medical waste as described e,
<br /> Print/Type Name A Signature W4. Date
<br /> 01 6
<br /> twe
<br /> 5. INTERMEDIATE HANDLER 2 ! TRANSPORTER 2 ADDRESS: Phone #:
<br /> ¢ i Applicable Permit Numbers;
<br /> ku
<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 #:
<br /> Applicable Permit Numbers:
<br /> R s a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Q � x
<br /> i Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 6A0 N . Foxboro Drive 2775 E . 28th 5t, 4858 BroaWake Road NE
<br /> IC I
<br /> 5tocktan , tA /� f arch Salt Lake , UT 84054 Vernon , CA 90058 Brooks, OR 87305
<br /> LL
<br /> (20g )N RNAN DEZ (, 01 )936 - 1171 (886)783-7422 (505 ) 393 -0890
<br /> Z TS SMO A-44t;lJA-38 reitimUF ood
<br /> 9 FEB 05 2022
<br /> a TREATMENT FACILITY: I certify that l have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> f-- receiv he abco Indicated wastes in accordance with the requirement outlined in that authorization .
<br /> t/T
<br /> PrinName Signature Date
<br /> I
<br /> l
<br /> ORiGtNAL
<br />
|