Laserfiche WebLink
MEDK:AL WASTE TRACKING FORM NUMBER <br />0,40 Stericyde* <br />1pCASE OF EMERGENCY ACT: CHEMTREC 1 STANDARD MANIFW ooi-te•AB•STD <br />Route j: 328 - 7 CUSTOMER Na 21 MDFROOBBUM <br />1. Generator's Name, Address and Telephone Number <br />ATTN: Pedro Gonzalez <br />Swan TRACY HOSPITAL <br />1420 N. TRACY BLVD. <br />TRACY, CA 95:376 <br />(209) 832-6032 8/3012011 <br />CUSTOMM Nurawn 6070156-002 GENU MTOn a RiIhI numoN # <br />2A. DESCRIPTION OF WASTE <br />20. CONTAINERTYPE <br />2C, N06 OF <br />20. VOLUME <br />UN3291, Regulated Medical waste. nos.,CONTAINERS <br />T857 - 90 Gal Tub ( ' 01 (12 Cu ft) <br />6.2, FGII <br />Cu Ft. <br />UN3291. Regulated Medial Waste, n.o.s., <br />6.2. PGII <br />g$49 - 37 Gal Tub (Rio) (9.9 Cu ft) <br />Cu FL <br />1Y <br />.Regulated Medical waste n.as., <br />Ga <br />TH14 - 44 l Tub (Sioi (3.9 Cu ft) <br />6.2. PGII <br />6.2, <br />CU Ft. <br />FFp <br />Q <br />UN3291 Regulated Medical waste, n.o- , <br />T92 L - 20 Gal Tub (Bio! (2.7 cu tt) <br />(r <br />6.2 . PGII <br />Cu Ft. <br />W <br />Z <br />UN3291 Regulated Medical Waste, n.os., <br />6.2, PGIi <br />TB15 - 20 Gal Tub (hath) (2-7 Cu ft) <br />Cu R. <br />t <br />('iUN3291 <br />Regulated Medical Waste, n.os., <br />6.2, PGli <br />TY15 - 20 Gal Tub Wh o) (2.7 cu ft) <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Who, n.os., <br />6.2, tall <br />Cu Ft. <br />Was <br />_gbarmaceutical <br />3. Generator's Certification: 11 hereby declare that the corNents of this consignment are fully and accurately TOTALS ® Al V I &l Cu Ft. <br />described aboe by the proper shipping name, and are alassHled, pacltageA mariced wW labded4gaceidad,and <br />are in all respects in proper condition for transport according to applicable International and national garemmentai regulations' <br />p� <br />Xt„(�c�=-i4f� rJ{l <br />Printecirryped Name Signature Date <br />cc <br />4. TRANSPORTER 1 ADDRESS: Phone #.- - <br />This is Through Shipment <br />Stericycle, Inc. a Applicable PermitNumbers: <br />4135 fit Swift Ave. Hauler Reg* 3400 <br />N <br />Eresno,Ca 93722 <br />TRANSPORTER FICAecelpt of mescal waste as devA <br />~ <br />T: —�a <br />pdrw type Name Signature Date grr <br />b. INTERMEDIATE HANDLER 2 /IFAANSPORTER 2 ADDRESS: # Phone C <br />a <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Reoelpt of medical werste as described above. <br />Print/Type Name Signature Dana <br />f <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #- <br />S <br />ApplicablePermit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Printflype Name Signature Date <br />7. DISCREPANCY INDICATION <br />Transferred containers, cu ft to : North San Lake, UT <br />® AA. Designated Facility: 88 FwUh[FOC. Alliernebe Fatuity: SD. AtterrA to Facility: <br />Sterisyde lnc-Aubodtive iia ccyytde Ino. In n Sten a Inc Autodav�a a Inc-Autodave <br />NORTH <br />a <br />4135 W. SHAFT AVE 90 1100 WEST 1345 Die DrNe Ste C 2775 E NTH STREET <br />U. <br />San Leo. CA 94577 VERNON, CA 90023 <br />FRESNO,CA 53722 NORTH SALT LAKE t <br />(559) 275- 1121 (801) 938- 1555 (510) 562- 2177 (3231 362 - 30M <br />W <br />TS/OST22 3A -448-.1A-36 T'S31ftSlOsiz TS/OST 26 <br />Pit <br />TREATMENT FACILITY: I mortify that I have been authorized by the applicable state agency to accept untreated medittel Wash and that i have <br />received the above indicated wastes in accordance with the requirement lined in that authorization. <br />MEA..'•!!M C"M <br />Print/Type Name Signature Date <br />AUG 30 20 <br />®� 3 <br />AUA. <br />