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—low MEDICAL WASTE TRACKING FORM NUMBER ®• Steri de" IN CASE OF EMERGENCY CONTACT: CHEMTREC 1. MO.424.93W STANDARD MANIFEST 001.10 -06 -SM ••• e . * CAL Route tt: 301 - 10 CUSTOMER N0.21132 MI)FROOC785 1. Generator's Name, Address and Telephone Number ATTN: GOLDEN LIVIUG iiYPA111A - 569 4545 SRELLEY COURT STL1G'1('lY U, CA 95207 6080856-001 2A. DESCRIPTION OF WASTE (209) 477-0271 GOMATOMS RECSTRATCN e 3. Generatoes Certification: "I hereby declare that the contents of this consignmem are tulty and a described above by the proper shipping name, and are classified, packaged, marked and labeitedlpl are in all respects in proper condition for transport according to applicable intemational and national A S . Printedrryped Name t signatu 4. TRANSPORTER t ADDRESS: w Stecicycle, Inc. This is a �c 4235 W. Swift St F reano, CA 9:3722 a a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. i ~ Print/Typs Name =� Y • Signage 4/11/2012 2C. NO.OF2D, VOLUME CONTAINERS and I TOTALS 0- Jc. ental regulations" j S. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described stove. Print/rype Name Signage i Phom r: (559) 275-0994 Applicable Permit Numbers: fouler Reg# Date Phone A: Applicable Permit Numbers: Date 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone 4: Appruxtke Permit Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. - Print/Typs Name Signature Date 7. DISCREPANCY INDICATION k .000 TrMUrfed cordahms. cu A to: North Sal lake, UT 'a r IN ossilgnsted Facility: 88. Alternate Facility: ® SC. Alternate Facility: Sterlcycle. etc.Inc. s^te"Cycle. Inc,. 4135 W. St 30 i 100 West x'0542 Sera Rrbnlo Street Frssno.CA 83722 North Safi take. UT 84059 HaWard, CA 92M (558) 275,11121 (801) MIM (510) 562-2177 TSIOST22 36 T53t/TSADST25 80. Alternate Facility: Sterlcycie, tnc. 2775 E. 26th St Vernon, CA 90058 (323) 362-33) C TS/OST 26 ENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have the above indicated wastes in accordance With the requirement outlined in that authorization. ORIGINAL ED r` a 6.2, poli T857 - 90 Gal Tub (trio) (12 cu ft) UN3291. Regulated Medical Waste, n.os.. 6.2, PGII TB49 _ 37 Gal Tub (trio) (4.9 cu tt) I Regulated Medial Waste, n.c.s., TB14 - 44 Gal Tub (Bio ) (5.9 Cu ft) Ic62N, P Q UNM1. Regulated Medical Waste. n.os.. T921 - 20 Gal Tub(Sio) (2.1 cu ft) 6.2, PGII W Z UN3291 Regulated Medical Waste, n.as.. 6.2. PGIi TB15 - 20 Gal Tub (Path) (2.7 Cu ft) W UN3291, Regulated Medical Waste. n.os., 6.2, PGII TY15 - 20 Gal Tub (Chemo) (2.7 cu ft) UN3291, Regulated Medical Waste, n.os., 6.2, PGII 3. Generatoes Certification: "I hereby declare that the contents of this consignmem are tulty and a described above by the proper shipping name, and are classified, packaged, marked and labeitedlpl are in all respects in proper condition for transport according to applicable intemational and national A S . Printedrryped Name t signatu 4. TRANSPORTER t ADDRESS: w Stecicycle, Inc. This is a �c 4235 W. Swift St F reano, CA 9:3722 a a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. i ~ Print/Typs Name =� Y • Signage 4/11/2012 2C. NO.OF2D, VOLUME CONTAINERS and I TOTALS 0- Jc. ental regulations" j S. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described stove. Print/rype Name Signage i Phom r: (559) 275-0994 Applicable Permit Numbers: fouler Reg# Date Phone A: Applicable Permit Numbers: Date 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone 4: Appruxtke Permit Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. - Print/Typs Name Signature Date 7. DISCREPANCY INDICATION k .000 TrMUrfed cordahms. cu A to: North Sal lake, UT 'a r IN ossilgnsted Facility: 88. Alternate Facility: ® SC. Alternate Facility: Sterlcycle. etc.Inc. s^te"Cycle. Inc,. 4135 W. St 30 i 100 West x'0542 Sera Rrbnlo Street Frssno.CA 83722 North Safi take. UT 84059 HaWard, CA 92M (558) 275,11121 (801) MIM (510) 562-2177 TSIOST22 36 T53t/TSADST25 80. Alternate Facility: Sterlcycie, tnc. 2775 E. 26th St Vernon, CA 90058 (323) 362-33) C TS/OST 26 ENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have the above indicated wastes in accordance With the requirement outlined in that authorization. ORIGINAL ED