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®,® rrotecdap People. Redudap Rbk; <br />MEDICAL WASTE TRACKING FORM NUMBER <br />AE OF EMERGENCY CONTACT: CHEMTREC 1-80042" STANDARD MANIFEST 001 -10.06 -STD <br />Route #: 134 — 9 CUSTOMER NO. 21132 MDFROOK10C <br />` <br />1. Generator's Name, Address and Telephone Number <br />Lit {L,i <br />2110 <br />(20D) 46G -8U75 12/20/2017 <br />j <br />6038112-002 <br />` <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINERTYPE <br />20. NO. OF <br />20. VOLUME <br />UN3291Regu!ated Madlcat Waste, n.o.s., <br />6.2, PGI) <br />TD08 — 40 Gal Tutt (Hiro} (S , 3 Cu ft) <br />CONTAINERS <br />_ Cu Ft. <br />UN3291� Regulated Medical Waste, n.o.s., <br />T'B49 - 'T1 Gal Tub oio (4, 9 Ou m <br />Cu Ft. <br />i <br />®i <br />UN3291 Regulated Medical Waste, R.o.s., <br />6.2, PGI) <br />Til$ Sal Tub(Bio) (5-9 Cu t t) <br />Cu Ft <br />II <br />UN 91I Regulated Medical Waste, n.o.s., <br />TB21— (gap)/TPi5— (Path) /TY15— (Chemo) 20 Gal Tub (2.7cuFT) <br />Cu Ft <br />W ' <br />Z <br />UN3291 Regulated MOW Waste, n.o.s., <br />6.2, 1`1311w1331— <br />(Sia) /WP31— (Path) IWC31— (Chemo) 31 Gal Tub (A.14CCIFT) <br />Cu Ft. <br />Regulated Medical Waste, n.o.s., <br />823PGI) <br />Id1343— (Sio) /FW43— (path) /CW43— (Chemo) Gal Tub (s.7CUFT) <br />Cu Ft. <br />' <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, poll: <br />MW — Biosystettrs Cardboard Box (4.2 cu ft) <br />Cu Ft <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, P611. <br />Cu Ft. <br />i' <br />UN3291 Regulated Medical Waste, n.o.s., <br />6 2, PGI)' <br />Cu Ft <br />3. Generator's Certification: "t hereby declare that the contents of this consignment are fully and accurately Z Cu Ft <br />anTOTALS <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, d <br />are In all respects in proper condition for transport according to applicable international and national governmental regulations" <br />U •• <br />xPrintedMped <br />! <br />Name Signature Dateia"~'l <br />cc <br />a. TRANSPORTER 1 ADDR S:ne # (866) 783-7422 <br />� <br />SteriCycle, Inc. This is a Through shipment Applicable Permit Numbers: <br />p. <br />iw <br />4135 Swift; Ave _ Hauler Res # 3400 <br />Fresno,CA 93722 <br />I a d: <br />TRANSPOR R ERTIFICATION: Receipt of medical waste as described above. <br />r; <br />3 <br />PrinMpe NaSignature \\ Date p6 �'� o �— <br />6. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS Phone #: <br />f 199 <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />i <br />PrinUlype Name Signature Date <br />M <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: <br />a <br />c <br />Applicable Permit Numbers: <br />N a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrEnt/iype Name Signature Date <br />j <br />e <br />T. DISCREPANCY INDICATION <br />I <br />4V— <br />Doaigruitod Facility: tie. Alternate Facility: 8C. Alternate Facility: 8D. Alternate Facility: <br />til <br />Sts cycle, Ina. Stedaycle, Inc. SWrlcycle, inc. <br />Drlva <br />13S W. S►MftAvs 90 N. Foxboro Drive 1651 Shelton <br />reano.3�-74�P'���E <br />ILI �� <br />( C'' `� is North Salt Lake, UT 84054 Hollister, CA 95023 <br />Z <br />(866)783-7422 (866)783-7122 <br />g <br />TSIOST22 31418 -UA -36 TSIOST 83 <br />PAJ! <br />DEC 2 0 20 <br />TREATMENT FACILITY: 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 1 d stes in accordance with the requirement outlined in that authorization. <br />� <br />PdnVTypo Name Signature Date <br />Tranderred conminers, a" ft to i <br />11 ORIGINAL <br />