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4 MEDICAL. WASTETRACKING FORM NUMBER Q®®® iN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.424-93 STANDARD MANIFEST 001 -1006 -STD 5ttisClCyC�@� ®'® eroterilagftopi .khtingftk CUSTOMER NO. 21132 Route Am 3141 1. Generator's Name, Address and Telephone N ATTER: 601 V Cnvromn JIT STOCKTO'N, CA 95202-» 2110 6,2, GENERATOA's REGISTRATION # •rretw — s c-ae TIAGAEzar Aa,v ME e.., TB21-taro)/TPIS-(Path)/TY1S-(Chemo)20 Gal Tub 6.2, PGII 3. Generator'a Cert ficatfon: "I hereby declare that the contents of this consignment are fully and accurately ®TAi-S 00- described ►described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and are in all respects in proper condition for trans prt according to applicable International and national governmental regulations" t lPrintedrPiped Name "7 4. TRANSPORTER 1 ADDRESS: �-' Stecicycle, Inc. 0 4135 W. Swift Ave rn FrO0110-� RI22 $ TRANSPORTERTIFI�A 10 Receipt of F Print/Type Na e ' 1 as 13 This is 2C. NO. OF CONTAINERS VOLUME —.11 _ Date Phone #: Shipment Applicable(A�ii!)ta7i�b3eTs7�22 Hauler Regi# 3400 Date 6. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:-- N lig I Ell INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, FPrint/Type Name Signature Phone #• Applicable Permit Numbers: Date Cu CuSTOMEn NUMBER go 2A. DESCRIPTION OF WASTE 5 ir W UN3291 Regulated Medical Waste, 6.2, PGII UN3291, Regulated Medical Waste, 6.2, PGII INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, 6 23 91 Regulated Medical Waste, p UN329i, Regulated Medical Waste, 62, PGIk Q is W UN3291 Regulated Medical Waste, 6.2, 171311 IZ UN3p91I Regulated Medical Waste, 6,2, GENERATOA's REGISTRATION # •rretw — s c-ae TIAGAEzar Aa,v ME e.., TB21-taro)/TPIS-(Path)/TY1S-(Chemo)20 Gal Tub 6.2, PGII 3. Generator'a Cert ficatfon: "I hereby declare that the contents of this consignment are fully and accurately ®TAi-S 00- described ►described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and are in all respects in proper condition for trans prt according to applicable International and national governmental regulations" t lPrintedrPiped Name "7 4. TRANSPORTER 1 ADDRESS: �-' Stecicycle, Inc. 0 4135 W. Swift Ave rn FrO0110-� RI22 $ TRANSPORTERTIFI�A 10 Receipt of F Print/Type Na e ' 1 as 13 This is 2C. NO. OF CONTAINERS VOLUME —.11 _ Date Phone #: Shipment Applicable(A�ii!)ta7i�b3eTs7�22 Hauler Regi# 3400 Date 6. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:-- N lig I Ell INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, FPrint/Type Name Signature Phone #• Applicable Permit Numbers: Date Cu 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: 5 ir W Applicable Permit Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, Printlfype Name Signature Date 7. DISCREPANCY INDICATION SA. Deatgnatod Facility: 8B. Alternate Facility: 8C, Altomate Facility: ❑ 8D. Alternate Facility. a 3tedcycle Inc. Sbariee Inc. Steficyate, Inc. 4135 W. §Q Ave 90 N. aotbaro Olive 13551 Shhelton ®rive u F.. Prasno.CA 8 OFtTV- North Salt Lake, UT 04064 HoilJster. CA 95023 Z (866)78x.74 (865)783-7922 (866)783-7422 WN TSMT22 3A44&%W39 MOMS TREATMENT FAC! l certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have receiv`ted the above Indic �%s In accordance with the requirement outlined in that authorization. Print/Type N,gme • r Signature Date �o Transferred containers, eu fl to Q we�ee•. ORIGINAL ,