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"®e000 MEDICAL WASTE TRACKING FORM NUMBER <br /> ® Steriry de• WIN CASE OF EMERGENCY CONTACT:CHEMEC 1 D MANIFEST o0t•10-05-M <br /> Houta® Newui.e ry�pe.aeY�q ettC —AjME ®. <br /> • - r <br /> I.Generator's Name,Address and Telephone Number <br /> ATTN: Alice Souligne II ill II I it I III <br /> CERNNEL MEDICAL CZN= 7 <br /> 701EMan ST <br /> STOCKTO111, CA 95202— 2628 <br /> Cusrom NutsCART pAIc"I S 't e , <br /> 2A.DESCRIPTION OF WASTE 2e.L52- CONTAINER TYPE 2C. Na OF 2D. VOLUME <br /> UN329J,Regulated Medial Waste.n.as., CONTAINERS 1 <br /> 6.2.PGR TB57 - ILGal Tub Sia 12 cu ft Cu Ft. <br /> i UN3291.Regulated Medical Waste,n.as., <br /> j 6.2,PGII T149 - 37 Gal Tub (Bio) (4.9 cu ft) Cu FL <br /> CC UN3291,Regulated Medical Waste,n.o.s., <br /> O 6.2,PG Id T914 - 44 Gal Tub Bio} (S.9 cu ft Z �' Cu Ft <br /> Q UN3291,Regulated Medical Waste.n.as., <br /> Q5.2,PGR T1321,- 20 tial Tub(Bio) (2.7 cu ft) t Cu Ft <br /> W UN3291.Regulated Medial Waste,n.o.s., <br /> Z 6.2,PGII 1`815 - 20 Gal Tub (Path) (2.7 cu $t) Cu Ft. <br /> Uj f:7 LW 291 Regulated Medical Waste.n.0.s., <br /> Eal - 29 091 Zub Whim) Q-2 mi C11 Cu FL <br /> 229r�11i Regulated Medical Waste,n.o.s.. <br /> Cu Ft. <br /> i UN3297,Regulated Mediad Waste,n.o,s., <br /> 6.2.PGII Cu Ft. <br /> i <br /> Cu Ft. <br /> I a � <br /> 3.Generator's Certification:-I hereby declare that the Contents of this consignment are fully and accurately T®TALS 0- i 1°S Cu Ft. <br /> described above by the proper shipping narne,and are classified,packaged,marked and IabeRed/placarded,and <br /> are in all respects in proper ndition for transport according to applicable International and national govemm Tal regulations" <br /> I1 <br /> Primew Typed Name Signature Date 14 I1 <br /> 4.TRANSPORTER f ADDRESS: Phone e: 75 - <br /> Stericycle, Inc. Applicable Per <br /> a o 4135 Vent-Swift Ave. <br /> a I Fresno Ca 93722 •rhis is a couq shipmeec <br /> a a TRANSPORTER CERTIF16MON:Receipt of medical waste as described above. <br /> Print/type Name R�yV. l ail-1-0 Signature Date !� " <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone Y: <br /> Applicable Permit Numbers: <br /> R <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medicat waste as described above. <br /> ! Print/Type Name Signature Date <br /> Lu S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone tt: <br /> w 9 C9 Applicable Permit Numbers: <br /> 0 <br /> i <br /> wl 2 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> I 7.DISCREPANCY INDICATION <br /> S <br /> }. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> ORIGINAL <br />