|
1111C.:110 �@t'I� C1e MEDICAL WASTE TRACKING FORM NUMBER
<br /> 1111C.:110• S y R4"ASE lie EIS&MENCY CONTACT:CHEMTREC 1-8CU-424-93nn S'Mjgr�"lF�-�kgg).-03-21,NocA
<br /> CUSTOMEF NO.2111 ............
<br /> TEAR HELE ------------
<br /> 1.Generator's Na6�1E� p {��r �S an -T le h ne Number
<br /> ,ff p /t r R 0RM GAPS1lItDl�ilI,a (��� SERVICE RECEIPT
<br /> PU �4yA., K I o ACCODUT C: 6 167 40 3-0)1
<br /> 2131 f`IYOSEMITE AVE Pure Form callary and Tattoo
<br /> M LECA,( A 95336-5803 SEFVICE DATE: 6!25!2021 10:23:29 AM
<br /> 1209)2C4-99251 DRIVER ID: 6alaviz, Lorenzo
<br /> SHIPPING DOCUMENT : MDFROOOZIIZ
<br /> 6167403-001
<br /> CUSTOMER NUMBEF GENERATOR s REGISTRLTION 4 TOTAL COLLECTED:
<br /> 2A.DESCRIPTION OF WASTE 26• CONTAINER TYPE TOTAL VOLUME: 2.700 CU FT
<br /> E
<br /> UN3291,Regulated Medical Waste,n.o.s., T804 -28 Gal Tub(810)(3.7 cu R)
<br /> 62,PGII OOAOOOZ TB21 Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., C CU VOL6 2,PGII Cu Ft,
<br /> X UN3291,Regulated Medical Waste,n.o.s., 10 QTY CF
<br /> 0 62,PGII SUHHARY(Cont Type;
<br /> ~ UN3291,Regulated Medical Waste,n.o.s., C�FL
<br /> 62,PGII ��� � T521 20 Gal Tub CrisP(Bio) 5.7 1 2.700
<br /> Cc Ft.
<br /> W 1-ItJ3291,Regulated Medical Waste,n.o.s_
<br /> Z 6?,PGII Cu Ft.
<br /> 11J
<br /> 1-11,13291,Regulated Medical Waste.n o.s., _ r Gal U
<br /> 6 2,PGII^ ) DRIVER: Calaviz, Lorenzo
<br /> Cu Ft.
<br /> 1-11,13291,Regulated Medical Waste,n.os., ^"' - WS $ITIS Cardboard {uf Cu }
<br /> FREQUERCY: N:A
<br /> 6 2,PGII IkXT PICKUP: 01!A Cu Ft.
<br /> U43291,Regulated Medical Waste,n.o.s., CUSTOMER SERVICE: Steric cle
<br /> 6.2,PGII Thank you for choosing Y C Ft.
<br /> !JN3291,Regulated Medical Waste,
<br /> 6.2,PGII Cu Ft.
<br /> 3.Generator's Certification:"I hereby declare that tie contents of this consignment are fully aid accurat-31y
<br /> TO Cu Ft.
<br /> described above by the proper shipping name,and a•e classified,packaged,marked and labeiledIplacarded,and
<br /> are in all respec's in proper condition fcr transpor,alxording to applicable international and national goye -Tciital regula
<br /> tX Printed/Typed Name ) Signature -= V
<br /> cc 4.TRANSPORTS=I$ ,Inc. This is a Thr0Ugh StOpi' ent Phone .
<br /> s o Fr1"sft,CA V3721
<br /> _ En
<br /> y a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Cr
<br /> ~ Print/Type Name Signature Date r 1
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> 'uu Applicable Permit Numbers:
<br /> ;ate
<br /> :oW
<br /> �w= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medics wase 33 described above.
<br /> ,r
<br /> �Z
<br /> Print/Type Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> C a cc cc Applicable Permit Numbers:
<br /> [W J
<br /> n�a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Recent of medical waste described above. _
<br /> w=�_
<br /> Signature Date
<br /> ~�
<br /> Print/Type Name—. _
<br /> 7.DISCREPANCY INDICATION _
<br /> Y 8A.Designated Facility: 88. er to F tillty ((��8C.Alternate r9clltty: n 8D.Alternate Facilitv:
<br /> sm rir Ic.tna lAla$ e3 'r a} ,Tne.1inr�neretvr) `ateilCyde,Inr .(Autodave) overrte Mahon, me
<br /> #3 "vAft 4 0 N,FCNbQr'*Caries► 1+56` Shety Me 48 0 Eroohiake Road NE
<br /> r�er!o, Ooft Sea Lslr:a,LOT 84054 Hollister,CA 35423 Brooks, OR 9730*.
<br /> (80783-11422 8i3i 3 -SIli (888)783-74-.2 (5113)393-08913
<br /> N A-dA�B�,A-38 TSt0. T-83 Perrrdt*364
<br /> Ec
<br /> TREATMENT FACILITY: I certify that I have Veen authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> � !received the above indicated wastes'.n accordance with the requirement outlined it thaT authorization.
<br /> nature Date
<br /> print/Type Name
<br /> iC�ltTBtlll�b� 1 aIR9T5, tail 2 to 'N-Saft Lake,UT
<br /> LE =.{ ate
<br />
|