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9/2/2010 11:50 Remote ID <br />0 6 Stericycte' <br />®•® ft@*.m1ftwwk: <br />rint ID <br />IN CASE OF EMERGENCY CONTACT: CNEMTREC 1.600.234 WSI <br />Dnu1-o Ale 317111 - 7 <br />I. Generator's Name, Address and Telephone Number <br />ATTN: <br />BEVERLY CHUM STOCKTON #1567 <br />1222 ROSMUME LANE <br />STOCKTON, CA 95207 <br />9RDT-3M.'S011 <br />_D_2/8 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001 -1006 -STD <br />111111111111111111111111111111111 <br />GaNs%xrwv vies e <br />N <br />7 <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINFIR TYPE <br />2C. NO. OF <br />20. VOLUME <br />REGULATED MEDICAL. WASTE, n.o s..6.2, <br />CONTAINERS <br />UN 3291. PG II <br />TB57 - 90 Gal Tub (Rio) (12 Cu it) <br />Cu Ft <br />REGULATED MEDICAL. WASTE, n.o s..6.2, <br />tel 3291, fps L <br />T949 - 37 (mal 'tub (trio) (4.9 cu ft) <br />Cu Ft <br />REGULATED MEDICAL WASTE, n.o.:.,6.2 <br />UN 3291, PG 11 <br />TB1! a 14 r'al rub (Bio) (S. 9 ou tt) <br />11 <br />1 <br />rJ , 9 Cu Ft <br />REGULATED MEDICAL WASTE, n.o.s..6.2. <br />T82L - 20 Gal Tub (IIYio) (2.7 cut ft) <br />UN 3291. PG II <br />Ft <br />REGULATED MEDICAL WASTE. n.o.s.,6.2, <br />UN 3291, PG II <br />11815 - 20 681 Tub (Path) (2.7 Cu !t) <br />Ft <br />REGULATED MEDICAL WASTE, n.c.s..6.2. <br />UN 3291, PG II <br />TriS - 20 Gal Tub (Chemo) (2.7 au ft) <br />CM Pt <br />REGULATED MEDICAL WASTE, mos -.6.2. <br />UN 3291, PG II <br />Qu Ft <br />REGULATED MEDICAL WASTE, n.o.s.,6.2. <br />LIN 3291. PG ii <br />Cu F <br />amarmlitic <br />CU EL <br />3. GenanitWs Ca 9fl : 9 hereby declare that the contents of this consignment are fairy and accuratelyTML$ <br />Awe.rehaA .Ma.r las. ere. wrnw.e .NweJwea w..n. e.A ..n A...me.A w..&—A —A -A ..A m.a.e.Arwm.,..we.A <br />® <br />� <br />e:Y . Cu FL <br />are In all respcis in r condition f6r ftnsW according to applicable irttertlatiortal artdnaftnai oval Wdow <br />JOAUQ 201 5 9aup9 <br />Pr ed tare Dale <br />cc 4. TRANSPORTER 1 ADDRESS: Phone s: 5 <br />Stericycle, Inc. Applicable PermTl uu rrss: 76 - 0994 <br />4235 Neat. Swift Ave. <br />Fresno, Ca 93722 This Tht:ou shipment„s <br />TRANSPORTER CERTIFICATION: Roo* of medical waste as described above. <br />Printfrype Narne "e. V • f Signature Date 4 'S o 9 <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />r <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Phone N: — <br />Applicable Permit Numbers: <br />PrInt/Type Nam Signature Date <br />y 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone 0: <br />AppOkade Permit Numbers:INTERMEDIATE HANDLER /TRANSPORTERRecut at CERTIFICATION: Recat mediad waste as described above. <br />PrInVtjrpe Name Signature Data <br />10 <br />T. DISCREPANCY INDICATION <br />11 <br />TREATMENT FACILITY: 1 <br />received the above Indical <br />Name <br />0 asr0w <br />• i <br />9e., c r-SLJN VALLEY, CA 2 1352 <br />4m 'K{. <br />that I have been authorized by the applicable state <br />Ies4racoordance with the r"Wrement Dudi <br />w G-�R&naturo Z404 <br />$0. Alternate Facility: <br />STER!ICYCLE INC <br />2778 E 28TH STRIIET <br />VERNON, CA 90023 <br />(3231362.300D <br />P-6, P-1 15 <br />to acpot untreated medical wastes and that I have <br />Data _ _SEP 0 9 2009 <br />