|
MEDICAL WASTE TRACKING FORM NUMBER
<br />�® Stericycle IN CASE OF EMERGENCY CONTACT; CHEMTREC 1.800.424-9300 STANDARD MANIFEST 001.10-06STO
<br />•.• rawect4®P�taseaockgN.k: Route 0: 100 — 24 CUSTOMER NO. 21132 MDFROODUSS
<br />1. Generator's Name, Address and Telephone Number `` f
<br />C2QjF0RWM M 1010 L rACILI'TY
<br />1617 It CALINORNA ST
<br />S`POCKT` —N, GA 95284-- 6.:17
<br />(09) 948-6435 7/2/2013
<br />CusTommNumsER 6039652--002 GENERATOR'SREGISMnoN#
<br />2A. DESCRIPTION OFWASTE 2s. CONTAINERTYPE 2C. NO. OF 20. VOLUME
<br />BUM Regulated Medical Waste, n.o s.l CONTAINERS
<br />8.9. Pali 'T805 — 4.0 Gal Tub (Bio) (5.3 ca ft) r.l! M
<br />Pharntaceutlea1 waste
<br />3. Generator's Certification -11 hereby declare that the contents of this consignment are fully and accurately
<br />LLS111
<br />described above by Ute proper slVpping name, and are classified, packaged. marked and labeiled/plaoarded, amt -----
<br />are in alt respects m proper condU�rt fo/r tlransport according to appitcabla mtemaUOnal acrd naNanal gavammental regulatlons'
<br />Prinledflyped Name � r �/`"� � �� 8fgnaia�reL�'��
<br />4. TRANSPORTER i ADDRESS:
<br />St:ericycle, Inc,
<br />4735 V. swift Ave
<br />Ecesao, CA 93722
<br />x TRANSPORTER CERTIFICATION: Receipt r
<br />L2
<br />Q This is a Through Shipment
<br />waste as described above.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Phone #: (559) 276-1121
<br />Applicable Permit Numbers:
<br />Hauler; F.egr# 3400
<br />Data
<br />Ph" IN.
<br />Applicable permit Numbers:
<br />PdnVlWe Name Signature Date
<br />G. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phona #:
<br />Applicable Permit Numbers:
<br />e INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Prmiliype Name Signature Date
<br />7.
<br />BA. Designated Facility:
<br />Staricycle.Inc.
<br />41nW...SMftA\M
<br />i-reano,`iAS3 22
<br />Tmns€emed containers, du tiff to : North Salt Lake, UT
<br />88. Alternate Fadlity:
<br />St>3ftcle, Inc.
<br />90 North Foxboro or
<br />North Sal Lake, tai W54
<br />(801) 93Fi-1566
<br />akdlilgv"S
<br />6C. Attematc Facliity:
<br />Stericycle, Inc.
<br />1661 Shelton Drive
<br />HDtllstet•, CA 950
<br />(831) 830-11698
<br />TWOST83
<br />811. Allernate Fadilly.
<br />Stericycle, Inc,
<br />2775 E. 26th St
<br />Vernon. CA 90058
<br />(323)862-3000
<br />TS/OST 26
<br />DALE ANNE ORTIZ I I I
<br />'HENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />d tha ja aboV2n "3d wastes i accordance with the requirement outlined in that authorization.
<br />re Name 4� t Signature Data
<br />I�
<br />e
<br />ORIGINAL
<br />UWARIi naguiatau meaicai waste, n a.s.,
<br />6.2, Pali
<br />`PB49 — 37 Gal Tub (B:.o) (4.9 Cu tt )
<br />CC
<br />NMRegulated Medical Waste, nos.,
<br />U
<br />TB14 — 44 Gal b (Bio) (5.9 Cu ft)
<br />Tu
<br />Q
<br />2 Pail
<br />4
<br />6N GII Regulated Medical Waste, nos„
<br />TB21. — 20 Gal Tub (Bio) (2.7 cu ft)
<br />W
<br />w
<br />UN3291 Regulated Medical Waste, n.®.s.,
<br />6.2. Pali
<br />TF15 r 3t1 Gal Tub (Path) (2.7 cu Et)
<br />&2N2 sill Regulated Medical Waste, n.a.s,
<br />TY15 — 20 eal Tub (Chemo) (2.7 -ou ft)
<br />UN3291 Regulated Medical waste, n a s.,
<br />62, PGII
<br />1 — Biosystems
<br />systems Cardboard Bose (4.2 au ft}
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />/ I/ -r , .ue „ , ._
<br />Pharntaceutlea1 waste
<br />3. Generator's Certification -11 hereby declare that the contents of this consignment are fully and accurately
<br />LLS111
<br />described above by Ute proper slVpping name, and are classified, packaged. marked and labeiled/plaoarded, amt -----
<br />are in alt respects m proper condU�rt fo/r tlransport according to appitcabla mtemaUOnal acrd naNanal gavammental regulatlons'
<br />Prinledflyped Name � r �/`"� � �� 8fgnaia�reL�'��
<br />4. TRANSPORTER i ADDRESS:
<br />St:ericycle, Inc,
<br />4735 V. swift Ave
<br />Ecesao, CA 93722
<br />x TRANSPORTER CERTIFICATION: Receipt r
<br />L2
<br />Q This is a Through Shipment
<br />waste as described above.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Phone #: (559) 276-1121
<br />Applicable Permit Numbers:
<br />Hauler; F.egr# 3400
<br />Data
<br />Ph" IN.
<br />Applicable permit Numbers:
<br />PdnVlWe Name Signature Date
<br />G. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phona #:
<br />Applicable Permit Numbers:
<br />e INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Prmiliype Name Signature Date
<br />7.
<br />BA. Designated Facility:
<br />Staricycle.Inc.
<br />41nW...SMftA\M
<br />i-reano,`iAS3 22
<br />Tmns€emed containers, du tiff to : North Salt Lake, UT
<br />88. Alternate Fadlity:
<br />St>3ftcle, Inc.
<br />90 North Foxboro or
<br />North Sal Lake, tai W54
<br />(801) 93Fi-1566
<br />akdlilgv"S
<br />6C. Attematc Facliity:
<br />Stericycle, Inc.
<br />1661 Shelton Drive
<br />HDtllstet•, CA 950
<br />(831) 830-11698
<br />TWOST83
<br />811. Allernate Fadilly.
<br />Stericycle, Inc,
<br />2775 E. 26th St
<br />Vernon. CA 90058
<br />(323)862-3000
<br />TS/OST 26
<br />DALE ANNE ORTIZ I I I
<br />'HENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />d tha ja aboV2n "3d wastes i accordance with the requirement outlined in that authorization.
<br />re Name 4� t Signature Data
<br />I�
<br />e
<br />ORIGINAL
<br />
|