|
o* stericycle, IN CASE OF EMERGENCY CONTACT: CHEMTREC
<br />hda"FACPk ftlec6paw cusm
<br />r
<br />1. Generator's Name, Address and Telephone Number
<br />I
<br />ATTIC,
<br />CALIFOR't12k M&OICA , FACILI'1rY
<br />1617 'gi CALIFORNIA ST
<br />S`3tC mTog, CA 96204- 6117
<br />3, Generator's Certifioatton:'I hereby dedare that the contents of this consignment are fully and a
<br />described above1 the proper shipping name, and are classdaed, packaged, marked and labelled/pi
<br />are in all respects n proper condi or transport acwrding to applicable international and national
<br />Ir
<br />Pdnt ed Name Signati
<br />4. TRANSPORTER i ADDRESS.
<br />Stec%CIN o, Inc. This is a
<br />4135 V. Swift Ave
<br />Fresno fes. 93722
<br />a. f�� TRANSPORTER C RTIFICNION: Reoeipt of medical waste as described above.
<br />~ Print/Type Name ffikZi Signature G
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />i
<br />a
<br />Nrs
<br />Z
<br />to
<br />119
<br />cc
<br />l F
<br />C
<br />I C
<br />'c
<br />,
<br />'WAWTE TRACKING! FORM NUMBER\
<br />STANDARD MANIFEST e01-1o•oe-STO
<br />21132
<br />2C. NO. OF 120. VOLUME
<br />CONTAINERS I
<br />TOTALS 0-
<br />and
<br />r latro &° iT/
<br />6-:�ff,4 Date �I ,
<br />Phone 9: Ps are. fgppa a;-1121
<br />Shipment Applicable
<br />H-aulac Regi# 3400
<br />Date
<br />Phone 9:
<br />Applicable Permit Numbers:
<br />jINTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medicatwaste as described above.
<br />Ptlnftpe Name Signature t
<br />6. INTERMEDIATE HANDLER 9 /TRANSPORTER 3 ADDRESS:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as t
<br />PrinViype Name Signature '
<br />above.
<br />Date
<br />Phone t#:
<br />Applicable Permit Numbers:
<br />Date
<br />CUSTOMER NUMBER
<br />GENERATOR'S RF
<br />cu ft to j Narth Sal Lake, UT
<br />2A. DESCRIPTION OF WAST
<br />CONTAINER TYPE
<br />® 813. Attemate Facility:
<br />UNMI Regulated Medical Waste, n.o.s.,
<br />6.2, Pell
<br />Is C33 It
<br />Stent ydtr Inc.
<br />ON3291 Regulated Medical Waste, nos.,
<br />6.2, PGIE•nab
<br />r 8 .
<br />pG
<br />UN3291. Regulated Medical Waste, n.o.s.,
<br />4135 VY.
<br />p
<br />62, Pon
<br />r'
<br />E. St,
<br />UN3291 Regulated Medical Waste, nos.,
<br />6.2, PGI{
<br />TH21 — 20 GaZ Tttb (s i o) (2.7 cu ft)
<br />W
<br />UN3291 Regulated Medical Waste, MO.%.
<br />Vumon, CA 90068
<br />Z
<br />6.4 PGIi
<br />'r Ott
<br />(031) 3ga-Im
<br />182si 3a -mica
<br />UHngl Regulated Medical Waste, n.os., 001
<br />- Y - -
<br />3, Generator's Certifioatton:'I hereby dedare that the contents of this consignment are fully and a
<br />described above1 the proper shipping name, and are classdaed, packaged, marked and labelled/pi
<br />are in all respects n proper condi or transport acwrding to applicable international and national
<br />Ir
<br />Pdnt ed Name Signati
<br />4. TRANSPORTER i ADDRESS.
<br />Stec%CIN o, Inc. This is a
<br />4135 V. Swift Ave
<br />Fresno fes. 93722
<br />a. f�� TRANSPORTER C RTIFICNION: Reoeipt of medical waste as described above.
<br />~ Print/Type Name ffikZi Signature G
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />i
<br />a
<br />Nrs
<br />Z
<br />to
<br />119
<br />cc
<br />l F
<br />C
<br />I C
<br />'c
<br />,
<br />'WAWTE TRACKING! FORM NUMBER\
<br />STANDARD MANIFEST e01-1o•oe-STO
<br />21132
<br />2C. NO. OF 120. VOLUME
<br />CONTAINERS I
<br />TOTALS 0-
<br />and
<br />r latro &° iT/
<br />6-:�ff,4 Date �I ,
<br />Phone 9: Ps are. fgppa a;-1121
<br />Shipment Applicable
<br />H-aulac Regi# 3400
<br />Date
<br />Phone 9:
<br />Applicable Permit Numbers:
<br />jINTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medicatwaste as described above.
<br />Ptlnftpe Name Signature t
<br />6. INTERMEDIATE HANDLER 9 /TRANSPORTER 3 ADDRESS:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as t
<br />PrinViype Name Signature '
<br />above.
<br />Date
<br />Phone t#:
<br />Applicable Permit Numbers:
<br />Date
<br />received the above Indicated wastes n accordance with the requirement outlined In that aut orization.
<br />PriApe Na 87013 Signature
<br />Of- �_ :11 90
<br />Date
<br />Trauferreff
<br />mdalrors,
<br />cu ft to j Narth Sal Lake, UT
<br />L.J SA.Doslgnated Facility:
<br />® 813. Attemate Facility:
<br />❑ 80. AHemate Facility:
<br />® 8D Aibmate Facility:
<br />Stent ydtr Inc.
<br />Madvi % Inc.
<br />surlcyc% Inc.
<br />Sterlcycle, Inc.
<br />4135 VY.
<br />90 1y1�00 est
<br />IJriva
<br />E. St,
<br />y alei�tyAyvp�a
<br />f reano�,krA-93 22
<br />,AN��,aM
<br />N�T& Lake. Ur
<br />11505I� �S,�QEfit►n
<br />8-tVt313*Wdr IEA am
<br />Vumon, CA 90068
<br />(669) 275-1121
<br />(5011) 936-1555
<br />(031) 3ga-Im
<br />182si 3a -mica
<br />6
<br />TSItJSi'$S
<br />iS16ST-26
<br />AU VE
<br />TRE&fts11LtWT66rtlfy
<br />thal
<br />I have been authorized by the applicable state agency Ito accept untreated medical wastes and that I have
<br />received the above Indicated wastes n accordance with the requirement outlined In that aut orization.
<br />PriApe Na 87013 Signature
<br />Of- �_ :11 90
<br />Date
<br />
|