Laserfiche WebLink
0 0 <br />`e stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800.424-WuO <br />o • v"1u*0Ptst° X tdudr W Route 6: 100 - 22 CUSTOMER NO. 211`132 <br />MEDICAL WASTETRACKING FORM NUMBER <br />STANDARD MAMFEST 001-10.0-STO <br />MDFROODOVD <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />CALIN]CRMA MEDICAL FACILITY <br />1617 'N CALIFCRMA ST <br />STOCKTON, CA 56204- 6117 ' <br />(2119) 948-6435 S/712013 <br />t <br />CUSTOMER NUMBER 6039652-002 GENERATORsRiiaWRAnolae <br />2A. DESCRIPTION OF WASTE <br />20. CONTAINERTYPE <br />2C. NO. OF <br />20. VOLUME <br />l <br />Medical Waste, n.a s <br />6 2, Pall Pall <br />c <br />TENS - 40 "L Tub (Bio) (5.3 u Ift) <br />CCONTAINERS, <br />Cu Ft. <br />UN 2 f Regulated Medica! Waste, n.o s., <br />TB49 — 37 Cab �j (viol (4.9 t;:t) <br />Cu Ft <br />cc <br />UN3291 Regulated Medical Waste, n..s., <br />,e <br />,pg1q _ 44 Gal (gj a) (g. g u �Iv} <br />p <br />6.2, PGI <br />Cu Fla <br />UN3291, Regulated Medical Waste, n os., <br />T821 — 20 Gal Tub (bio) (2.7 cut ft) <br />(C <br />6 2. P611 <br />Cy Ft <br />W <br />2 <br />UN3291 Regulated Medicai Waste, n o s, <br />6,2, PGi� <br />Tft5 — 2* Gal Tall iPa tli) (2,7 CU it~) <br />Cu Ft <br />1 <br />66.2.PGlIRegutatedMedicalWaste,no.s, <br />THIS — 20 Gal Tub jC12 o) $2_7 ca ftp <br />Gu Ft. <br />8 2, Pail{ Regulated Medical Waste, n o,s, <br />UB _ Biosystems Cat dboard Box (4.2 ca t9t) <br />Cu FI <br />291 Regulated Medial Waste, n oa, <br />5A P611Cu <br />In <br />Ft <br />phanaaceuticax Waste <br />Cu Ft <br />I Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/plaearded, <br />are In all respects In proper oo for tr nsport according to applicable International and national govern tal re a. <br />7— <br />KI G 7 <br />Name Signature Date <br />A. TRANSPORTER I ADDRESS Phone ti: (569) 276-1121 <br />This IS shilment <br />Stericyc1eo Inc. a Through <br />Applicable Permit Numbers <br />4'136 10. Swift St Resp# X400 <br />Fresno,C:A -43722Saui�>r <br />a <br />TRANSPORTER CERTIFICATION:PTP ipt of medical waste as describ ab <br />J "% <br />Prtnoi ps Name gnature _ _ Date <br />6. INTERMEDIATE HANDIER 2 /TRANSPORTER 2 ADDRESS: Phone #: <br />Applicable Permit Numbers <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recatot of medical waste as described above <br />Printityps Name Signature Data <br />S. INTERMEDIATE HANDIER $/TRANSPORTER 3 ADDRESS: Phone #: <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recut of medical waste as described above. <br />— <br />Prfnttfype Name Signature Date <br />7. DISCREPANCY INDICATION <br />s%rreti >`:ot Wners, cu ft to : Nadh Sal take, UT <br />QDSA. <br />Designated Facillty: 8B. Altemate Facility: ® 80, Alternate Facdityr ® 81) Alternate Faclllty: <br />Sudcycte, Inc. Sbmilcycle,Inc. ftedqyde. Inc. Sterlgxle, Inc. <br />4185 W. $Olt St sv Akwm 'iloa wad 1651 Sta b n 0tw 2M E. 26th St; <br />Fresno.cAmm Norio malt Lake, UT 04VA Her, CA SSW Vernon, CA SCIE168 <br />(E 275 tYt (Slit) 836 (831) 63S-1f34I8 (828) 36 0 <br />to <br />TS SLAVE it4 36 Tafm83 TSIOST-26 <br />DALE ANNE ORTIZ <br />TREATMENT FACILITY: I certify that have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />I.. <br />rece0d ftrVlMd wastes accordance With the requirement outlined in that authorization. <br />Prrpoyyps Name Signature Date <br />to <br />