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<br />Atli Stericydw
<br />www.e.myem.
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 424 STANDARD MANIFEST 001-10-MSTD
<br />Route 5: 301 - 9 CUSTOMER NO. 21132 MDFROOC869
<br />Generator's Name, Address and Telephone Number
<br />Ar
<br />!N:
<br />Gob LIVING RYPAHA - 569
<br />4545 SSELLEY COURT
<br />swmwv, CA 95207
<br />�uoioims�Am��m�umieioioi
<br />(209) 477-0271
<br />4/18/2012
<br />3. Generators Certlfleation: "I hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />described above by the proper shipping name, and are classiried, packaged, marked and labslledlpiacarded, and
<br />are in all respects in proper condition for transport according to applicable international and national governments t regulations.'
<br />5.9 Cu FI
<br />Printecirryped Name L • �' / ®v Signature Date
<br />4. TRANSPORTER 1 ADDRESS: Phone R: (559) ?75-
<br />stericycle, Inc. This is a Through Shi enAppileatile Permit Numbers:
<br />4135 W. Swift St Hauler Reg#
<br />a. Fcenno,CA 93722
<br />y
<br />a TRANSPORTER CERTIFICATION: Receipt of medical waste as descried above.
<br />Print/Type Name JV . eS„ Signature
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />ca
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />Print/type Name Signature
<br />Ric6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Ris
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />iPrinVType Name Signature
<br />I T. DISCREPANCY iNDICATIDN
<br />f T , cu A to : North Salt Lake, UT
<br />Date �� r
<br />Phone p:
<br />Applicable Permit Numbers:
<br />Date
<br />Phone 8:
<br />Applicable Permit Numbers:
<br />Date
<br />10-
<br />11
<br />8A. Destgruded Facility:
<br />CUSTOMPANUMSER 6080856-001
<br />GmmyowsREcusmnowa
<br />stxrlcy�' Inc.
<br />swkyde. Inc.
<br />2A. DESCRIPTION OF WASTE 28.
<br />4196 W. 9VM St
<br />CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />North S'ait Lake, UT 84M
<br />HaWmd, CA 94544
<br />(659) 275.4121
<br />(801) 913rr1555
<br />(510) SSZ2477
<br />8 -JA -36
<br />UN3291, Regulated Medical Waste, n.o.s.,CONTAWERS
<br />T857 -
<br />90 Gal Tub (Biot' (12 Cu ft)
<br />Cu Ft.
<br />6.2.PGii
<br />UN3291, Regulated Medical Waste, ri&&,
<br />T849 w
<br />37 Gal Tub (Bio) (4.9 cu ft)
<br />FL
<br />6.2, PGII
<br />Cu
<br />29i Regulated Medical Waste. n.O.s.,
<br />T814 _
<br />44 Gal Tub (gio) ES. 9 Cu t0I
<br />5 FL
<br />O6
<br />I
<br />Cu
<br />Regulated Medical Waste, n.o.s.,
<br />T821 -
<br />20 Gal Tub (BiO) (2.7 cu ft)
<br />fi 23291,
<br />PGII
<br />Cu Ft
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TBlS - 20 Gal Tub 4Path) (2.7 Cu ft)
<br />I Z
<br />62, PGiI
<br />Cu Ft
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2. 1`1311
<br />TY15 - 20 Gal Tub (Chemo) 42.7 cu ft)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGiI
<br />Cu Ft.
<br />UN3291, Regulated Medical Wage. n.o.s.,
<br />3. Generators Certlfleation: "I hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />described above by the proper shipping name, and are classiried, packaged, marked and labslledlpiacarded, and
<br />are in all respects in proper condition for transport according to applicable international and national governments t regulations.'
<br />5.9 Cu FI
<br />Printecirryped Name L • �' / ®v Signature Date
<br />4. TRANSPORTER 1 ADDRESS: Phone R: (559) ?75-
<br />stericycle, Inc. This is a Through Shi enAppileatile Permit Numbers:
<br />4135 W. Swift St Hauler Reg#
<br />a. Fcenno,CA 93722
<br />y
<br />a TRANSPORTER CERTIFICATION: Receipt of medical waste as descried above.
<br />Print/Type Name JV . eS„ Signature
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />ca
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />Print/type Name Signature
<br />Ric6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Ris
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />iPrinVType Name Signature
<br />I T. DISCREPANCY iNDICATIDN
<br />f T , cu A to : North Salt Lake, UT
<br />Date �� r
<br />Phone p:
<br />Applicable Permit Numbers:
<br />Date
<br />Phone 8:
<br />Applicable Permit Numbers:
<br />Date
<br />10-
<br />11
<br />8A. Destgruded Facility:
<br />86. Alternate Facility:
<br />8C. Anamala Facility:
<br />stxrlcy�' Inc.
<br />swkyde. Inc.
<br />Stericytie, Inc.
<br />4196 W. 9VM St
<br />90 mom 1100 Wwd
<br />30542 San Ardorft Street
<br />Fresno,CA 93722
<br />North S'ait Lake, UT 84M
<br />HaWmd, CA 94544
<br />(659) 275.4121
<br />(801) 913rr1555
<br />(510) SSZ2477
<br />8 -JA -36
<br />T93iAVf0M5
<br />80. Attemato Facility:
<br />Steacycile. Inc.
<br />2775 E.26'th St
<br />Vernon, CA 901458
<br />(323)362-30M
<br />TS(OST 26
<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 ANNE f7FMZ
<br />PrinUT Name Signature Date
<br />APR 18 2012
<br />
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