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TVowMEDICAL WASTE TRACKING FORM NUMBER <br />® SterlcyclW IN CASE OF EMERGENCY CONTACT: CHEMTREC 14OD-424-93M STANDARD MANIFEST 001.1e46.STD <br />'® Route 6: 301 - 4 CUSTOMER NO. 21132 MDFRO005GP <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />GOLDEN <br />�7�..Z��tIpip4isCOURT - 569 <br />4545 SBELLE <br />STOCKTDbi, CA 95207 <br />(209) 477-0271 3/26/2012 <br />CusTwEnNulltm 6080856-001 G€wRAnowsREo+sTR ym0 <br />2A. DESCRIPTION OF WASTE 20• CONTAINER TYPE 2C. NO. OF 2D. VOLUME <br />UN3291 Regulated Medical Waste, nos., T957 - S0 Gal Tub (Srio) (12 Cu ft) CONTAINERS <br />6.2, PGii Cu FL <br />UN PGI. Regulated Medical waste, n.os.. T849 - 31 Gal TUb Mall (4.9 cu tt) Cy FL <br />® 6.23291, Regulated Medical Waste, n.os., 9 ; 44 Gal Tub (Sia) (3.9 CU ft) <br />Cu Ft. <br />4 UN3291, Regulated Medical Waste, mos., i - 20 Gal Tub (Bio) (2.7 cu ft) <br />6.2, PGII Cu Ft. <br />UJ Z UN322991) Regulated Medical Waste, n.o.s.• 1815 - 20 Gal Tub (Path) (2.7 cu ft) <br />Cu FL <br />UN3291 Regulated Medical Waste. n.o.s.. <br />6.2, PGI, TY15 - 20 Gal Tub (Chem*) (2.7 cu ft) Cu Ft. <br />UNMI, Regulated Medical Waste, mus.. <br />6.2, PGO I Cu Ft. <br />UN3291, Regulated Medical Waste, n.os., <br />Pharmaceutical Mast Cu Ft. <br />3. Generator's Certification: `1 hereby declare that the contents of this consignment are fully and accurately TOTALS ® Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and carded. arrd -� <br />are in all respects In proper condition for transport acconSing to applicable international and national governmental regulations." <br />Pdnted%ped Name a � Signature Datg,�"' � <br />4. TRANSPORTER 1 ADDRESS: Phoned: (559) 275-1121 <br />aStericyCle, Inc. ❑ This is a 'through Shipment AppiicabfePermitNumbers: <br />a 4135 lit Swift Ave. Bauler Reg# 3400 <br />R Fresno, Ca 93722 <br />CL o�C TRANSPORTER CERTIFlGATION�:`Receipt <br />of�medical waste as described above. <br />~ PrinUiMpe Name 1 /Signa Date _ <br />5. INTERMEDIATE HAbC0ER 21 TRANSPORTER 2 ADDRESS: Phone* <br />N ApplikaNe Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above- <br />Print/Type Name Signature Date <br />ie 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone e: <br />3 a Applicable Permit Numbers <br />a INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />Traimbffed rs, cu Q to : Nadh Sat Lake, UT <br />ar <br />SA. OuNinsted Facility: <br />u 88. Alternate Facility: <br />u eC. Alternate Facility: <br />u SD. Alternate Facility: <br />.J. <br />Inc-A <br />Ire Indn <br />Inc <br />Stertcoe Inc -Autodeve <br />0 <br />4135 W. SW1= PAYE <br />so NOR7H I tooV%EST <br />1345 Dvo0o Drive Ste C <br />2775 E 26TH STREET <br />FRESNO.CA 93722 <br />NORTH SALT LAKE CITY, t3 <br />San Leandro. CA 94577 <br />VERNON, CA 80023 <br />►- <br />(559) 275 - 1121 <br />(80!)936- 1555 <br />(5 10) 562 - 2177 <br />(323) 362 - 3000 <br />t'g <br />JA -36 <br />TS3 i <br />-26 <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable stat® agency to accept untreated medical wastes and that 6 have <br />I- <br />received the above indicated wastes <br />in accordance with the requirement outlined <br />in that authorization. <br />ALE S OFITIZ <br />PrinVTypo Name 9dEi} <br />snatuze <br />Date <br />t•,R 2 7 2012 <br />