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O. -N-19 5ter" cteE
<br />ttMcnA�Y•Redudepgdt.
<br />MEDICAL WASTETRACKiNG FBRPi NUMBER
<br />111 CASE OF ��ppA4ERQ>;NCY CONTACT: CHEMTREC 1.800.424-9800 STANINARD MANIFEST 001.10aW STD
<br />RDtti:e 1 : It1U — 21 CUSTOMER NO. 21132' MDFR0090UU
<br />. Generator's Name, Address and Telephone Number
<br />AWN;
<br />CALIFOMA 14LPDxCAL FACILITY
<br />1617 V CAUTORNIA ST
<br />STOCKWN, Ch 95244- 6117
<br />iiiiiiiiiiiiiiiiiiiiiillillisilliI
<br />(2/18) 848-6435
<br />816/2013
<br />3. Generator's Cartittcation: h hereby declare that the contents of this consignment are fully and accurately TOTALS 0 -
<br />described above by the prayer ping name, and are classified, packaged, marked and labedeWplacarded and
<br />are in all respects in props n for trans ing to applicable international and national govemmen regulations."
<br />X :PrIntedflyped Name f`r Signature Date
<br />4. TRANSPORTER t ARDRE (5&3, 275-1121
<br />SteRC:yC e, C:. Thla is a Through SMipment
<br />4135 A. Applicable Permit Numbers
<br />a EreSno,GA 93722v$ Hauler Reg# 3400
<br />a TRANSPORTER CERTIFICATION: ERTIFICCATIO -Al Receipt of medical waste as described
<br />�+� `/�. ,.y(►
<br />FRMAUw Nmnn i\� &I 17 t1I1
<br />.,, a. viv a crzp,ev,n, a nnrvvaere cr , nra,varun I en c nuuncoo: ("none ii:
<br />N
<br />Ing
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER,/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />' PrnJlYpe Name Signalure
<br />Date _
<br />3 ADDRESS:
<br />INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Prfnt/type Name Signature
<br />Phone 0
<br />Applicable Permit Numbers:
<br />Date
<br />081 tamers, ou ft to : North Salt Lake, UT
<br />J
<br />a
<br />w
<br />609652"002
<br />IJ 08. Attomato Facility:
<br />Steric'ycle, Inc.
<br />90 Nota F Or
<br />With Sett Mita. UT $409
<br />(801)9313-1665
<br />3A-44SJAr36
<br />CustomEnNumaER GENERAmn,sREateriumaN#
<br />L] W. Ahemate Facility.
<br />S%ricycle. Inc.
<br />2776 E. 26th 4
<br />A 058
<br />3.00
<br />TS145T 26
<br />2A. DESCRIPTION OF WASTE
<br />29. CONTAINERTYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />UN3291 Regulated Medical Waste. n.o s.,
<br />6.2,
<br />TgOg - 4U�, TUb (>3io) iS.3 t�1 1;t)
<br />CONTAINERS
<br />Pell
<br />CU Ft.
<br />B PGIi RegWated Medical Warta, n os,
<br />TB49 — 37 Cal. Tub (Dio) (4.9 au tt)
<br />Cu Ft.
<br />W
<br />29iRegulated Medical Waste, n.os.,
<br />TB14 — .44 Gell. Tub (Sip) (S. 9 cu 1:t)
<br />8UN
<br />ii
<br />Cu FL
<br />U ti Rqulated Medical Waste, n.os.,
<br />Ml — 201 Gal Tub (Sio) (2.7 CU tt)
<br />Cu Ft
<br />W
<br />ON3291. Regulated Medical Waste, n.os.,
<br />fit, PGOCu
<br />TP15 — 2'1t Gal Tub (Path) {2,7 aft ft)
<br />W
<br />FL
<br />UN929f Regutatad Medical Waste, n.a.s.,
<br />6.21 NilTY15
<br />— 21 Gal, Tub (Chemo) (2.7 au tt)
<br />Cu Ft.
<br />Regulatei Medical Warts, n a.s„
<br />62, Pell
<br />100 — Siosystetas Cardboard Box (4.2 ecu ft)
<br />Cu FL
<br />2 2299111 Regulated Medical Waste, nos.
<br />,,/ws,
<br />kp
<br />ff
<br />Cu PL
<br />P$arina,dieutical Waste
<br />3. Generator's Cartittcation: h hereby declare that the contents of this consignment are fully and accurately TOTALS 0 -
<br />described above by the prayer ping name, and are classified, packaged, marked and labedeWplacarded and
<br />are in all respects in props n for trans ing to applicable international and national govemmen regulations."
<br />X :PrIntedflyped Name f`r Signature Date
<br />4. TRANSPORTER t ARDRE (5&3, 275-1121
<br />SteRC:yC e, C:. Thla is a Through SMipment
<br />4135 A. Applicable Permit Numbers
<br />a EreSno,GA 93722v$ Hauler Reg# 3400
<br />a TRANSPORTER CERTIFICATION: ERTIFICCATIO -Al Receipt of medical waste as described
<br />�+� `/�. ,.y(►
<br />FRMAUw Nmnn i\� &I 17 t1I1
<br />.,, a. viv a crzp,ev,n, a nnrvvaere cr , nra,varun I en c nuuncoo: ("none ii:
<br />N
<br />Ing
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER,/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />' PrnJlYpe Name Signalure
<br />Date _
<br />3 ADDRESS:
<br />INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Prfnt/type Name Signature
<br />Phone 0
<br />Applicable Permit Numbers:
<br />Date
<br />081 tamers, ou ft to : North Salt Lake, UT
<br />J
<br />a
<br />w
<br />1-19A. Designated Facility:
<br />sirlwC1o,1no.
<br />413& K SWRAW
<br />Fresno,LIA 93722
<br />(SM) 275-1121
<br />IJ 08. Attomato Facility:
<br />Steric'ycle, Inc.
<br />90 Nota F Or
<br />With Sett Mita. UT $409
<br />(801)9313-1665
<br />3A-44SJAr36
<br />L] 8C. Alternate Faculty:
<br />ftricydo, inc.
<br />1551 Shoiton ®live
<br />H01118tar. CA 95023em
<br />(831 tail) -1688
<br />TS/08T as
<br />L] W. Ahemate Facility.
<br />S%ricycle. Inc.
<br />2776 E. 26th 4
<br />A 058
<br />3.00
<br />TS145T 26
<br />9
<br />AUTOCLAVE
<br />cc ITREWMEM, FACILff 7.1 I`certify th it 1 have been authorized by the applicable state agency to accept untreated medical wastes and that i have
<br />li received the above Indicated wraste in accordance with the requirement outlined in that authorization.
<br />Prtef/T eU 6 2013 Signature Date
<br />a--(- `.
<br />
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