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P)yar3Ra+reutdtetal itTa>Atxt
<br />Cu
<br />S. Generator's Certlft sdon:'I hereby declare that the contents of this consignment are fully and accurately HH�
<br />Cu FI
<br />described above by the pr r piling name, and ars classified, packaged, marked and labelled/placarded, and
<br />are In ell respects in o Ikon for trap port accords g to applicable International and national gov ulabona /% y�
<br />PrintedlTyped Name signature ate e– "
<br />4. TRANSPORTER i ADDRESS:
<br />StericKle, Ino. This is a Through
<br />4135 V. Swift Ave
<br />a. ruesno,CA 93722
<br />El
<br />TRANSPORTER CERTIFI ON: Receipt of mechcaiwaste as described above.
<br />{ .•e_._ �.—
<br />PdnVNoe NamsAh k .-1 __.— _ Stanature -
<br />Phone # (559) 276-1123
<br />Applicable Permlt Numbers:
<br />Harslet: Reg# 3400
<br />Date
<br />S. INTERMEDIATE MANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #:
<br />Fq cV
<br />Appyable Ferfrirt Numbers.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTSCATION: Receipt of medical waste as described above.
<br />NIPVTyps Name Signature Date
<br />e IL INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #.
<br />Hsi Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pflnt/rype Name Signature
<br />Date
<br />'AEPANGY INDICATION
<br />I Transferred containers, cu It to : North Sad Lake, HJT
<br />Designated Facility:
<br />_
<br />OC. Alternate Facility:
<br />® OD. Alternate Facility:
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />@.®
<br />f a * Steriryde'
<br />IN CASE OF EMERGENCY CONTACT: CREMTREO 1.000.424-8300 STANDARD MANIFEST 001-10.0"TD
<br />@•0 PN KftPeat* aod®d^vat:
<br />Amte z 1110 – 28 CUSTOMER NO.21132 f4DFROODZI9
<br />90 With Fathom Or
<br />1. Generator's Name, Address and Telephone Number liiiiiiiiiiiiiiiiiiiiillie�ilililI ATTU:
<br />2775 E. 26b St
<br />FMInA 14MCAL FACILITY
<br />Kurth Sat Lake, UT M54
<br />1617 N CALIFORIUA ST
<br />Vt mon, CA 90058
<br />ST017MR, CA
<br />96204— 6117
<br />(831) 63ti-1098
<br />I=) 362"-30a
<br />(209) 946-6435 7/23/2013
<br />s
<br />CuevomERNumaw 6039652-002 GeNaRATOR'SReatsTRArION#
<br />TWOST 26
<br />2A. DESCRIPTION OFWASTE 28.
<br />CONTAINERTYPE
<br />20. NO. OF
<br />20. VOLUME
<br />UN3291 Regulated Medical Waste, n.o S,
<br />T'BOS – 40 Gal. Tab (Bio) (5.3I cu ft)
<br />CONTAINERS
<br />6.2, PGif
<br />Cu Ft
<br />6 PGIf Regulated & tlical Waste, n o s.,
<br />TW 9 – 3:T Gael ',I.'ub (Rio) (4, 9 +G�.t tt)
<br />22i
<br />Cu Ft.
<br />lz
<br />UN3nl Regulated Medical Waste, n.o.s.,
<br />'I 44 Qa Tub$SiU) (S.9 Cu tt)
<br />t
<br />tFj
<br />6.21 F6if
<br />Cu Ft
<br />UNMI Regulated Medical Waste, n.c s.,
<br />X 2t� r�az Tub (sign) _ amt )
<br />,m
<br />6.2. Poli
<br />Cu FL
<br />Ulf
<br />UNE91 RagulatedMediatWaste,n.os,
<br />&2, PGIi
<br />TP15 – ZO Gal Tub (Path) (3.7 ou ft)
<br />Cu Ft
<br />IU
<br />6.z PGaf Regulated Medical Wade, n.o.s,
<br />TYIS – 20 Gal Tub (Chem*) (2,7 au ft)
<br />tit Ft
<br />8.1 �iE Regulated Medical Waste, n.o.s ,
<br />YaM – lViasystems Cardboard Bax (4.2 ca ft)
<br />,.. �.
<br />P)yar3Ra+reutdtetal itTa>Atxt
<br />Cu
<br />S. Generator's Certlft sdon:'I hereby declare that the contents of this consignment are fully and accurately HH�
<br />Cu FI
<br />described above by the pr r piling name, and ars classified, packaged, marked and labelled/placarded, and
<br />are In ell respects in o Ikon for trap port accords g to applicable International and national gov ulabona /% y�
<br />PrintedlTyped Name signature ate e– "
<br />4. TRANSPORTER i ADDRESS:
<br />StericKle, Ino. This is a Through
<br />4135 V. Swift Ave
<br />a. ruesno,CA 93722
<br />El
<br />TRANSPORTER CERTIFI ON: Receipt of mechcaiwaste as described above.
<br />{ .•e_._ �.—
<br />PdnVNoe NamsAh k .-1 __.— _ Stanature -
<br />Phone # (559) 276-1123
<br />Applicable Permlt Numbers:
<br />Harslet: Reg# 3400
<br />Date
<br />S. INTERMEDIATE MANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #:
<br />Fq cV
<br />Appyable Ferfrirt Numbers.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTSCATION: Receipt of medical waste as described above.
<br />NIPVTyps Name Signature Date
<br />e IL INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #.
<br />Hsi Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pflnt/rype Name Signature
<br />Date
<br />'AEPANGY INDICATION
<br />I Transferred containers, cu It to : North Sad Lake, HJT
<br />Designated Facility:
<br />DOB. Altemate Facility:
<br />OC. Alternate Facility:
<br />® OD. Alternate Facility:
<br />Slats , Inc.
<br />Stsricyc le, Inc.
<br />SWricycle. Inc.
<br />Stericyde, Inc.
<br />+4138 W. StaRtAve
<br />90 With Fathom Or
<br />1551 Shobn Drke
<br />2775 E. 26b St
<br />Fresno,CA 93722
<br />Kurth Sat Lake, UT M54
<br />Hofter, CA SSW
<br />Vt mon, CA 90058
<br />(559) 2775.1121
<br />(801) gas -hiss
<br />(831) 63ti-1098
<br />I=) 362"-30a
<br />s
<br />Te, LOST 83
<br />TWOST 26
<br />AUTOCLAVE
<br />TREAT FA�eNP I cel41 that I
<br />received the above indicated wastes In
<br />Pdwry" NOAUL 2 3 2013
<br />11MMENi,=110
<br />been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br />dance with the requirement outlined in that authorization.
<br />Date
<br />
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