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i •'0 stericycle- <br />e.® ft0Y.M*'ft" <br />Remote ID IMI -int ID D 2/2 <br />MEDICAL WASTE TRACKING FORM NUMBEI <br />IN CASE OF EMERGENCY CONTACT: CHENTREC 1.800-234-0051 STANDARD MANIFEST 001-10-MSTD <br />Route S: 301 - 3 NDFR008TA9 <br />1. Generator's Name, Address and Telephone Number <br />ATTN 11 NU1 I I I I HIM111 1 III <br />BEVMY CEATEAU STOWON 0567 <br />1221 ROSEKMdELABS <br />swcnol, CA 95207 <br />(209) 477-2664 <br />12/23/2009 <br />c RNu R 6080855-001 GarMRATOR'sREtiISTRATit1NN <br />2A. DESCRIPTION OF WASTE 20. CONTA94ERTYPE <br />2C. NCL OF 2D. VOLUME <br />REGULATED WWAL WASTE. no.s.,6.2, <br />T1357 - 90 Gal Tub (Bio) (22 cu tt) <br />CONTAINERS <br />UN 3291. PG 11 <br />Cu P <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, 1949 - 37 Gal Tub (Bio) (4.9 cu tt) <br />UN 3281. PG 11 <br />Cu FI <br />iij <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, TB14 - 44 Gil TUb (Bio) (S • 9 Cu tt) <br />, 9 <br />Q <br />UN 3291 PG 11 <br />.� - Cu F1 <br />Q <br />REGULATED MEDICAL WASTE. n.o.s.,6.2. T82L - 20 Gal Tub (Bio) (2.7 cu tt) <br />UN 3291. PS IICM <br />FI <br />W <br />REGULATED MEDICAL WASTE. n.c.s.,6.2, ?B15 - 20 Gal Tub (Path) (Z. 7 Cu !t) <br />W <br />UN 3291, P611 <br />Cu Ft <br />3281, PG 8(Chemo)U.7 ATED MEDICAL WASTE, n.o.s..6.2, <br />UN TY15 - 20 Gal Tub Cu !t) <br />UN 32 <br />Cu F <br />REGULATED MEDICAL WASTE, n.o.S.A.2, <br />UN 3291, PG II <br />Cu Ft <br />REGULATED MEDICAL WASTE, n.o.s..6.2. <br />UN 3291. PG II <br />CuFt <br />Pharmaceutical mantel <br />CyF <br />3. tor's CertNieatlon: -1 hereby declare 11hat am oonWo of 91b consignment are fully and accurs" TOTALS III-' <br />$ . �' FL <br />described above by the proper shipping narne. and are deemed. Jtnarked and WmftdOacafdW, and <br />ars in all respects in proper condition far trartswit according to + ar tiorlN and national 9CVem 1 eat�lss' <br />• <br />• PrNt Name S furs <br />4. TRANSPORTER' ADDRESS: <br />Phone N: (559) 275 - 0994 <br />Stericycle, Inc. <br />Appkable Permit Numbers: <br />4135 Beat Swift Ave. <br />This is coca h shipment <br />Freano,Ca 93722 <br />,4 <br />TRANSPORTER CERTIFICATION: Rmxlpt of ' waste as above. <br />tt Z <br />~ <br />�seie. V <br />!d 7 <br />Printtiyps e _— $i0natufa Dat@ �� <br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N: <br />r <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIRCA71ON: Receipt of medical waste as described above. <br />PdnV" Name Signature Date <br />n <br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone N: <br />Applicable Permit Numb@rs: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Raoso of medical waste as described above. <br />PrOmps Name Signature Date <br />T. DISCREPANCY INDICATION <br />T cu R to : North Sit LW*. UT <br />> <br />aA 0864pMed FW": 0 as. Aftemm racov., 0C. Aaemsts FwA ty: <br />0 a0. Alurm.so I'acauty: <br />5 <br />INC STERICYCLE INC 311 CYCLE INC <br />S I MICYCLE INC <br />4135 W. SWFT AVE 90 NORTH t IW VNEST 9063 NORMS AVE. <br />2775E 21111TH STREET <br />FRE ,CA 93722 NORTH SALT LAKE CITY, UT SUN VALLEY, CA 91362 <br />VERNON. CA SM23 <br />(669) 275- 0994 (00 1) 936 - t (8 Is) 604 - 8937 <br />(323) 362 - <br />1, TSOOST26 TSIOST22 Clan V Indrarellon P 21- <br />P -ti, P-11 S <br />top accept untreated mescal wastes and that !have <br />TREATMENT -AGILITY: I certify that t have been authorized by the ap��41n <br />received thea i in accordance with the requireme,tth tion.®EC <br />S, 1009 <br />• <br />P Nasse eSignau" <br />Date <br />000391 <br />