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9/2/2010 12:01 Remote ID rint ID---- 1��� dh <br />T <br />3/3 <br />_ _D <br />• W MEDICAL WASTE TRACKING FORM NUM13EI <br />® 5teriey�cle' IN CASE OF EMERGENCY CONTACT: CNEMTREC 14u*234-Mi <br />STANDARD MANIFEST oot-to..STO <br />®° <br />""""''""""'W"ftk' Route #t; 301 - 4 <br />14DFROOBWBE <br />1. Generator's Name, Address and Telephone Number <br />AM <br />Y MMAU STOCKTON #567 <br />1221 POSIMMI LA <br />57DCK701, CA 95207 <br />(209) 477-2664 <br />1/13/2010 <br />Cusvowea Mumma 6080855-001 GeNs"Tows REaucta uou <br />2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />REGULATED MEDICAL WASTE, n.o s..6.2, <br />T07 - 90 Gal Tub (Sio) (12 cu ft) <br />CONTAINERS <br />UN 3291. PG II <br />Cu F <br />REGULATED MEDICAL WASTE, n.o s.,6.2, Tfl49 — 31 tial Tub (Bio) (4.9 cu tt) <br />UN 3291 PG II <br />Cu F <br />REGULATED MEDICAL WASTE, n.o.s..6.2, T914 - 44 tialub T(Bio) (5.9 Cu tt)LIN <br />' <br />Q� <br />3291, PG 11 <br />,S• Q Cu F <br />4 <br />REGULATED MEDICAL WASTE. n.o.s..6.2. T821 - 20 Gal Tub (Bio) (2.7 cu tt) <br />UN 3291, P6 9 <br />Cu F <br />W <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, ?815 - 20 Gal TO (Pitta) (2.7 Cu Lt) <br />W <br />UN 3291, PG II <br />Cu P <br />REGULATED MEDICAL WASTE, n.o.S.A2, <br />UN 3291. PG II TY15 - 20 Gal Tub (Chemo) (2.7 cu Et) <br />CuI <br />REGULATED MEDICAL WASTE, n.o.s.,6.2. <br />UN 3291. PG R <br />Gg FI <br />REGULATED MEDICAL WASTE, n.o.s..6.2. <br />UN 3291. PG 11 <br />Cy FI <br />Pharmaceutical ical Wast e <br />Cu Ft <br />& Generator's Certification: "1 hereby declare that the contents of this consignment are "and accurately TOTALS t► <br />1 Jr• 1 Cu Ft <br />described above by the proper shipping name, and are claseffied. packaged, marked and Iabsllsd/pMaeardsd, end <br />are in a9 respects in proper condition for transport acoording to applicable international and national gover ns." <br />a <br />�Prin +� <br />I3 to <br />Nacos�►'1' S Lure <br />pate <br />b <br />4. TRANSPORTER 1 ADDRESS: <br />Stericycle, Inc. <br />Phone N: (559) 75 --0994 <br />Appaacbte Permit Numbers: <br />4135 ftst Swift Ave. This its Thr®ug shipment <br />Fr no,Ca 93722 <br />2: <br />TRANSPORTER CERTIFICATION: Receipt of medical waste above. <br />l rt0 <br />Printf ype Name , ®• Signature <br />Data <br />n <br />L INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Phone M: <br />Applicable Pemdt Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Nam Signature <br />Date <br />n <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone s: <br />in <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANISPORTER CERTIFICATION: Receipt of medical Waste as described some. <br />PrWype Name Signature Date <br />T. DISCREPANCY INDICATION <br />cu 2 to: Nath Sal Ldn. UT <br />, <br />■ <br />tIA DOWWWW ftCliftr. 0 0. &C. AtteneM Faclaty <br />W. Aftemals Feeft- <br />91MCYCLE INC STERICYCLE INC SIERICYC2.E INC <br />STERICYCLE INC <br />4135 W. SVAFT AVE 90NORTH 1100VYEST 9MNORRISAVE. <br />2776 E 2111TH STREET <br />UR <br />ICI.CA 93722 N T CITY. UT SUN VALLEY, CA 91362 <br />VERNON. CA SM <br />(5E} 0094 ( 1) -1 (018) &M - 6937 <br />(323) 3662' <br />T331.Tsfosm TWO= CknVIndn&f1d0nPWft2Ir <br />M. P-I 15 <br />TREATMENT FACtLiTY:-I' eiti --that I'havebeen authorized by the t untreated medical wastes and that I have <br />received the above in ' s in accordance with the requirerne I <br />�A40ff$f c�R <br />13 2410 <br />P1RAnutyype t nm, t`aignaame <br />DateJaN <br />0100006 <br />