Laserfiche WebLink
IVt-UIUALWASTE TRACKING FORM NUMBER' <br /> IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800.424-9300 STANDARD MANIFEST 001-1 0-06-STD <br /> F" <br /> Route #: 823 - 6 CUSTOMER NO.21132 MDFRDDKVdRD <br /> :.•_ e,Address and Telephone Number <br /> N:Mary Nguyen <br /> DR RICK DD5 INC. <br /> Al <br /> aT <br /> • � �~� 95337- 5703 <br /> (289) 823-9218 8/14/2818 <br /> A6084572-001 GENERATOR'S REGISTRA110N# <br /> `ON OF WASTE 2B. CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> yl gulated Medical Waste,n.o.s. 1304 - 28 Gal. Tub (Rio) (3.7 ru ft} CONTAINERS Cu Ft. <br /> pollRegulated Medical Waste,n,o.s., Boy _91 37 Cal Ttlh (Bio) (4,9 au ft) <br /> Cu Ft, <br /> 291 PG11 Regulated Medical Waste,n.tr,s. , - 44 Gal Tub(Hio) (5.9 cu ft) Cu Ft. <br /> 291 Regulated Medical Waste,n.o,s., B2 { }/TP15-( )/TY15-( )20 Gal Tub(2.7CUFT) ,� Cu Ft <br /> 291,Regulatod Medical Waste,n.o.s,, <br /> PGR <br /> Cu Ft. <br /> 291 pGll Regulated Medical Waste,n,o s. 1B43--( )jWPd3-( )/WC42-( ) Gal Tub(5.7CUEIT) <br /> Cu Ft. <br /> 191 Regulated Medical Waste,n.o.s. <br />)Gli .R - Biosystems Cardboard Box (4.3 ou f1:) Cu Ft. <br /> Gly Regulated Medical Waste,n.o.s., <br /> Cu Ft. <br />!91 Regulated Medical Waste,n.o s., <br /> IN Cu Ft <br /> 3enerator's Certification:"i hereby declare that the contents of this consignment are fully and accurately 7TOTALS / Cu Ft. <br />�crlbed above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and <br /> In all respects In proper condition for transport according to applicable international and national gover e tal regulations:' f <br /> Printed%ped Name rm��( -44tdillla Signature 6 AZQM <br /> IANSPORTER 1 ADDRESS; Pho�`ZIU) 783-7422 <br /> SteriCycle, Inc. This is a Through shipment Applicable Permit Numbers- <br /> 4135 W. Swift Ave Hauler Reg# 3400 <br /> Freono,CA 93722 <br /> 4NSPORTE ERTIFICAT N: Recelpt o edlcal waste as describ a eve. vfq)v <br />!typo Name Signature Date <br /> TERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS' Phone#: <br /> Applicable Permit Numbers <br /> ERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />!Type Name Signature Date <br /> ITERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS; Phone M <br /> Applicable Permit Numbers: <br /> ERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br /> yType Name Signature Date <br /> ISCREPANCY INDICATION <br />,A.Deslgnatad Facility: Be.Altamate Facility: L]8C.Altemato Facility: L] 8D.Alternate Facility: <br /> rlcycle,Inc, tericycle,Inc, Stericycle,Inc. Covanta Marlon,Inc <br /> 5 W.SNiftAva E 0 N.Foxboro Drive 11561 Shelton Drive 4850 Brookleke Road NE <br /> ano,CA 93722 t lotto Salt Lake,UT 84054 Hollister,CA 85023 Brooke,OR 97305 <br /> 6)783-7422 ni)936-it71 888)783-7422 (505)393.0890 <br />'OST-22 DALE ANNE OFMx A-4481JA36 �16ST-83 Permlt#384 <br /> EATMENT F����ff �.[[��.c that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> 31�ed the abddtcafe �tes in accordance with the requirement outlined in that authorization. <br /> I/Type Name f d-,(Id _ Signature Date <br /> Transferred eontallners, eta ft to <br /> ORIGINAL <br />