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__ - 6 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />®` Sterlcycte' IN CASE OF EMERGENCY CONTACT- CHEMTREC 1.600.4244= STANDARD MANIFEST ODI-104*STD <br />.0 r+.neniv►ad.. a Route 0: 301 - 10 CUSTOMER No. 21132 MDFROOC69K <br />ORIGINAL <br />1. Generator's Name, Address and Telephone Number /[{ IN <br />A! rife <br />III <br />11raoLDI <br />�y v�,t{ UG <br />w LT.VL1�7 HYPAWl, - 5569i <br />4545 SHSLLET COWr <br />swcrm, CA 95207 <br />(209) 477-0271 4/4/2012 <br />CusoimNuuata 6080856-001 GiewmAtoasR&atsmAnott0 <br />2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3291, Regulated Medical Waste, e.o.s., <br />6.2, PGII T857 — 90 Gal Tub (Bio) (1.2 cu ft) <br />CONTAINERS <br />Cu Ft. <br />11N3291, Regulated Medical Waste, ao.s., 9 — 37 Gal Tub (B'io) (4.9 cu ft) <br />6.2, PGII <br />Cu Ft. <br />Q <br />623P1i Regulated Medical Wage,no.s. T814 — 44 Gal Tub(Bio) (5.9 CLI ft) <br />f <br />I <br />C� <br />/ Cu Ft. <br />Q <br />UN3291 Regulated Medial Wasie, n.a.s., T02L - 20 Gal Tub(13i*) (2.7 cu ft) <br />tZ <br />1 <br />Cu Ft. <br />W <br />Z <br />UN3291, Regulated Medical waste, n.os., TB15 - 20 6a1 ?ul► (Path) (2.? au !1) <br />6.2. PGII <br />Cu Ft. <br />11 <br />UN3291 Regulated Medial Waste, n.o.s., <br />6.2, PGII TY15 — 20 Gel Tub (Chem*) (2.7 Cu it) <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.os., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2. PGII <br />Cu Ft. <br />Cy F. <br />21aag=00016tia <br />3. Gener84or's Certification: % hereby declare that the contents of this consignment are fully and accurately T®TALL ` S ' Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, nd <br />are in all respects in proper Condition for transport acoording to applicable intemallonai and national glom tat regulations' <br />;V1 !� <br />Printedrryped Name Signature Date <br />4. TRANSPORTER t ADDRESS. Puce 4: (559) 275-0994 <br />Stericycle, Inc. ® This is a gh SbipmentAppiicabie Permit Numbers: <br />cc <br />413S t#. Swift St Hauler Reg# <br />24. <br />Freano,CA 93722 <br />a < <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />G 4W 12' <br />PrinU yps Name ® Signature Date <br />S. INITERME.DIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone o: <br />11 <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Refit of medical waste as described above. <br />Print(Type Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone A: <br />4 <br />Applicable Permit Numbers: <br />efo Q <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />Trwatw"awlKaur CSI A to . Nolth Sak Laker UT <br />6A. Deslgnstod Facility: [Too. Aftemata Facility: 6C. Aftamato Facility: M Attemato Facility: <br />Inc. <br />J <br />. Inc. Inc. , trte. <br />4 <br />4135 W. St 1100 2 Seat 2175 E. 2b"th St <br />Fresno.CAOM NorM Sat take. UT 84054 HryVMd, CA SM Vernon. CA ENS <br />(55M 275-1121 (801) M1555 (510) 562-2177 PM 367-3MO <br />$%W36 TS31nVOSM -26 <br />Pit <br />TREATMENT FACILITY: I Certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />DALE E <br />•, <br />PrinuType Signature Dam <br />APR 04 2012 <br />ORIGINAL <br />