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9%2/2010 11:50 Remote ID Im rint ID D 4/8 <br />dft- <br />®•® MEDICAL WASTE TRACKING FORM NUMELER <br />®® Steric}rcle' IN CASE OF EMERGENCY CONTACT: CHEMTREC i-a00.234.OtNS1 STANDARD MANMEET 001.1006 -STD <br />Rouge tis 301 - 3 MDFRO08CCT <br />I.Generator's Nam, Address and Telephone Number <br />ATTN I I! i Ili II !I i lson <br />! <br />BEVJCRLY CHRTZAU 5 N 4567 <br />1227, ROSEMME LKNE <br />STOCKTON, Caw► 95207 <br />(209) 477-2664 9/26/2009 <br />atuaznAron s RaaternAn�r e <br />Currown Mass" 091 <br />2A. DESCRIPTION OF WAsTs 25. CONTAP ER TYPE <br />2C. NM OF <br />2D. VOLUME <br />REGULATED MEDICAL WASTE, n.o.s.,6.2. <br />CONTAINERS <br />UN 3291, PG 11 TBS7 - 90 Gal Tub (Rio) (12 cu tt) <br />Cu Ft. <br />REGULATED MEDtCft WASTE, n.c.s.,6.2. <br />UN 3291 PG If T949 - 37 Gal Tub (Bio) (4.9 cu ft) <br />Cu Ft. <br />CC <br />REGULATED MEDICAL WASTE, n.os.AZ <br />LIN 3291, PG 11 T814 - 44 Gal Tub (Rio) (S. 9 au ft) <br />s , Cu Ft. <br />REGULATED MEDICAL WASTE, n.0A.6.2, T821 - 20 Gal Tub (Bio) (2.7 cu ft) <br />LII 3291 PG II <br />Cu Ft. <br />W <br />REGULATED WASTE, na.s..6.2, <br />L N 3291, PG 11 7015 - 20 Gal Tub ( Path) (2.7 cu ft) <br />Cy Ft. <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />LIN 3291. PG 11 3715 - 20 Gal Tub (Chen) (2.7 cu tt) <br />Cu Ft <br />REGULATED MEDICAL WASTE, n.0.3..0.2, <br />UN 3291 PG II <br />Cm Fl. <br />REGULATED MEDICAL WASTE, nx.s.,6.2, <br />UN 3291, PS 11 <br />u Ft. <br />3 's : I hateby declare that the contents of this consigrynent are fully and acoxately TOTALS Is. 1 Cu Ft <br />d above by by the name, and aro d marked and labelledt <br />are in all respects M proms conthtlan for transport accordkV to appombie international and national gova ons" <br />,1 <br />A&MJ®AW %) t®r—"A S Data <br />4. TRANSPORTER 1 ESS: Phone 0: <br />(559) 275 - 0994 <br />Stericycle, Inc. Appllcaols <br />4135 fwt Swift Ave. This is a C ugh Shipment: <br />Fresno,Ca 93722 <br />TRANSPORTER CERTIFICATION: Recept a medicate waste as described above. <br />PrtrrV type Nam, r Signature p 24 O <br />S. INITERMEDiAM HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone A: <br />a <br />Applicable Permit Numbere: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as dawrbw above. <br />PrkWPips Name Signature Date <br />A <br />m. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone e: <br />Pacmr< Numbers:INTERMEDIATE <br />ApPicablePonveype <br />R /TRANSPORTER CERTIFICATION: waste as above. <br />Nam signature Date <br />T. DISCREPANCY INDICATION <br />ou ato <br />iA Dower4wd Fsdft. W SC. Alternate Facility: W. Alternate Favi ft. <br />STERICYCLEINC STERICYCLE INC STEFRICYCLE INC STEMCYCL.E INC <br />4135 W. SWFT AVE 90 NORTH 1100 WEST 9M NORMS AVE. 2775 E 20H STREET <br />FRESN0.CA 93722 NORTH SALT LATE CITY, UT SUN VAL. ZY, CA 91362 VERNONCA 9 03 <br />(01) 3-154 (91 504- f22t 276 - t121 .3W0 <br />to TSOM Class V wdr*reom Permls 9t ®-S,P.115 <br />IY <br />TREATMENT FACILITY: I t I t18Ve been aWhorited by d1e aplllicab� to age aol lI untreated InetdC&I wastes and that I have <br />received due a w in rice with the requirement in <br />P man* •` . L..) 7;V Date—AUG 2 4 2009 <br />