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9/2/2010 12:01 Remote ID Imprint ID <br />®® ®® Stericycle, IN CASE OF EMERGENCY CONTACT: CHEMTREC 1400 ZM4051 <br />• o• <br />D 2/3 _ <br />MEDICAL WASTE TRACKING FORM NUMEtEI <br />STANDARD MAIaFEST 001.104*WD <br />1. Generators Name. Address and Telephone Number <br />A�N: II Iii Illlii I tail III <br />Brvmlr CIRMIJ STOCKTON 067 <br />1221 ROSEMARIE LANE <br />S7X1G7CDON, CA 95207 <br />CUSTOWN NUMaEA rIA0^91i Go URATars REMMAtrort 11 <br />2A. DESCRIPTION OF W CONTAINER TYPE <br />2C. NO. OF 20. VOLUME. <br />REGULATED MEDICAL WASTE, n.c s..6.2. <br />CONTAINERS <br />UN 3291. PG 11-xiItishCu <br />F <br />REGULATED MEDICAL WASTE. <br />UN 3291 PG 11 <br />Cu P <br />(C <br />REGULATED MEDICAL WASTE. n.o.s.,6.2, <br />UN 3291 PG 11 _ <br />p <br />+ Cu F1 <br />,4 <br />REGULATED MEDICAL WASTE, n o.s.,6.2, <br />UN 3291. PG 11 TB21 - 20 Gaal Tub (diol (2.7 cu 1Et) <br />Cy FI <br />W <br />REGULATED MEDICAL WASTE. n.o.s.,8.2, <br />W <br />UN 3291, PG II - <br />Cy FI <br />REGULATED MEDICAL WASTE. n.o.s..6.2, <br />IN 3291, PG II _ <br />Ft <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />UN 3291, PG II <br />u Ft <br />REGULATED MEDICAL WASTE, n.o.s..6.2, <br />UN 3291 PG it <br />Ft <br />& Gensrstors Cettitkadw`: w hereby declare that the conterft of this consignment aro fully and accurately TOTALS 0. <br />CM Ft <br />! j .9 Cu Ft. <br />described above by the proper g , and erre cla illed, merited and labellad/placarded. and <br />aro In all respects in proper condition for transport according to applicable IMsmational and national govemmenul r tions' <br />-: <br />K4=tnMdNanne /"1! <br />./ ture <br />Date g i® <br />4. TRANSPORTER 1 ADDRESS: <br />ars e; <br />3ter1cycle, Inc. <br />Applicable Pe4A5li%bA75 - 0994 <br />44135 Netst Swift Ave. 0 Thin is Shipment <br />a co <br />f <br />TRANSPORTER of 1 waste as described above. <br />(�:.��/�R� <br />/l <br />C S <br />PrInMpe V/is'ti / Serrature <br />Date <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: PhoneM s: <br />r <br />NZ <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recut of medical waste an described above. <br />Printr ype Name Signature Date <br />oe <br />a. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone N: <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdrWType Name Signature Date <br />7. DISCREPANCY INDICATION <br />_' <br />` <br />AAFaci My 8a. Alaertete F tj <br />sD. Fadthtr. <br />j(STERICYCLE <br />INC 9TERICYCLE INC STERICYqE INC <br />3TERICYCLE INC <br />4135 W. SWIFT AVE 90 NORTH I 100 WEST SION NORMS AVE. <br />2778 E 213TH STREET <br />FrRESNO.CA 93722 NORTH SALT LAKE CITV. UT SUN VALLEY, CA 91352 <br />VERNON. CA SM <br />(SM) 275 - OW (SDI) - 1555 (818)504- 6937 <br />(323) 362 - 3000 <br />1, CM= V In 9 t <br />P-8, P611 S <br />it <br />FE <br />TREATMENT FACILITY: i certify that'l have been authorized by the applicable stat .agency to accept untreated medical <br />received the above indicated Ayaste4 in nce with ftregLdrernent n that tlud�lofiaation <br />wastes and that 1 have <br />% <br />Name tura <br />Date 22010 <br />U � •t j 4; 47 Q <br />