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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 001049P Stericycle' OASE OF EMERGENCY CONTACT:CHEMTREC 1-80"24-9 STANDARD MANIFEST 001-10-06-STD
<br /> Protecting People.Reducing Risk, CUSTOMER NO.21',32
<br /> 1.Generator's Name,Address and Telephone Number
<br /> 311111111
<br /> S.634 N tEyl.illl
<br /> -XTk.114, VA
<br /> CUSTOMER NUMBERJ 2 GENERATOR'S REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO.OF 21D. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., CONTAINERS
<br /> 6.2,PGII 'I'D 5'1 -90 Ga1 T1;i6 ?H, f.L.21 'ft) Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s..
<br /> 6.2,PGII 1 T4iP !'Sits) 14,9 r11 tt Cu Ft.
<br /> X UN3291,Regulated Medical Waste,n.o.s..
<br /> 6.2,PGII Tft1.4 44 Gal T u b bi 0, t 5,9 r_"A it Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> TEI2 ��O Ga 1. s27.3 C'u ft}
<br /> Ir 6.2,PGII Cu Ft.
<br /> W UN3291,Regulated Medical Waste,n.o.s.,
<br /> Z 6.2,PGII TB-3 5 - Z(! GAA TUb iPat.11.1; -1'Z-_,' CU it) Cu Ft.
<br /> Lu
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2.PGII TY1 5 - 20 o s:1 Ttzb (0)cm-0 (2'.7 �u ft) 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 Ft.
<br /> Cu Ft.
<br /> 3 Generator's Certification:"I hereby declare that the contents of this consignment are fully a I nd accurately [TOTALS 00- 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 govern, ental regulations".,
<br /> XPrinted/Typed Name Signature f- Date
<br /> 4.TRANSPORTER 1 ADDRESS: Phone#: Ci
<br /> IM
<br /> LU U9 111,1,3 in A 'JTfi;-,DU-_1b `,�h j,11111E?U�pplicable Permit Numbers:
<br /> Q r.73.1 f
<br /> .40
<br /> 2 C h
<br /> Z TRANSPORTER CERTIFICATION: Receipt of medical waste as describld above.
<br /> IM
<br /> Print/Type Name Signature Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS:
<br /> Lu
<br /> LOUC tM
<br /> �E r3 Lu
<br /> 0 UA
<br /> Q. Z
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described
<br /> SERVICE RECEIPT
<br /> cc—
<br /> Print/Type Name Signature
<br /> I ACCOUNT It! 6011F'10-0
<br /> Lu 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: San Joaquin Del Ill Col I College
<br /> �cc SERVICE DATE: 8124112 9:18:14 AN
<br /> U,
<br /> Ic
<br /> LU
<br /> DRIVER 10: Parra, Rene
<br /> 0 LU
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described
<br /> Z�= SH I PP I NG DOCUMENT T,_VFRO0CQA3
<br /> F Print/Type Name Signature
<br /> TOTAL COLLECTED: 2
<br /> 7.DI CREPANCY INDICATION 1 -7 TOTAL VOLUME: 8.600 CU FT
<br /> Containers, ft to Nori. O0A0OG1 T814 OOAOOGO TB15
<br /> Z]8A.Designated Facility: 8B.Alternate Facility; 8C.Alternate Facility: VOL
<br /> _j i Mr' We
<br /> SUNNARY(Cont Type) QTY CF
<br /> 00',;'4est n642-on An'o,
<br /> LL t
<br /> saiL(T 118,;-,vam',CA S- T014 44 Gal Tub(Bio). CT 12.7 1 5.900
<br /> Z
<br /> TB15 20 Gal Tub(Path), CT 5.7 1 2.700
<br /> f. 4
<br /> :01 5
<br /> lu -2 5
<br /> Ts. 1`S!013
<br /> DRIVER: Parra, Rene
<br /> W
<br /> TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to acceP FREQUENCY Weekly
<br /> received the above indicated wastes in accordance with the requirement outlined in that authorization NEXT PICKUP, 8131112
<br /> CUSTOMER SERVICE:
<br /> Print/type Name Signature Thank you for choosing Stericycle
<br /> LEAVE AT GENERATOR
<br />
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