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MEDICAL WASTE TRACKING FORM NUMBER <br />Go Sterigtie` IN CASE OF EMERGENCY CONTACT. CHEMTREC 14800424-49110 STANDARD MANIFEST aot'ta o6 SrD <br />• ft" " ne Rouge #: 301 - 4 CUSTOMER NO. 21132 NDF'ROOCA6U <br />t. Generator's Name, Address and Telephone Number <br />ATTH: <br />GOLDEN LIVING QYPAIR - 569 <br />4545 SHELLEY COURT <br />sTlOcMv, CA 95207 <br />�umei�umom��a�umni�ou <br />(209) 477-0271 <br />GsumA orrs REcmn ym 0 <br />6.2. PGI I <br />T957 - 90 Gal Tub (Bio) (12 cu ft) <br />UN3291, Regulated Medial Waste, n.o.s., 1 T.I. gi) (4 9 f -u ft) <br />6.2, PGII <br />UN3291. <br />Q 6.2. PGII <br />Q UN3291, <br />6.2, Poll <br />W11113291, <br />W 6.2. PGl <br />i 2, PGII <br />Regulated Medical Waste. n.o.s., <br />TB49 - .3T Gd ( o - <br />TBL4 - 44 GAL Tub (Sio) (5.9 cu ft) <br />Regulated Medial Waste, nos., <br />TO21 - 20 Gal Sub (bio) (2.7 cu ft) <br />Regulated Medical Waste, n.os.. <br />T815 - 2q Gal Tub (Path) (2.7 cu ft) <br />Regulated Medical Waste. n.o.s., <br />TY15 - 20 Gal Sub (Chem+*} (2.7 cu ft) <br />Regulated Medial Waste, n.o.s.. <br />(559} 27s-1121 <br />TSADST22 <br />Regulated Medical Waste, n.o.s.. <br />Vernon, Cao 90056 <br />3. Generator's Certlfkation: 'I hereby declare that the contents of this consignment are fully and accurately <br />described above by the proper shipping name. and are classitled, packaged, marked and labeltediplacarded. <br />are in all respects in proper ition for transport according to applicable international and national governs <br />i <br />PrintedtTyped Name Signih:�� <br />4. TRANSPORTER 1 ADDRESS: <br />Lis Stecicycle, Inc. This is a <br />41:35 A. Swift St <br />g rl Fcesno,CA 93722 <br />a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />R76~ PrinitType Name Rs " ° Signature <br />5 INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />51212012 <br />2C. NO. OF 20. VOLUME <br />CONTAINERS <br />TOTALS Do- <br />ti <br />tgulatio s" <br />7 <br />Date •2 //2 <br />Ptrortes (.5-59)27&-4994 <br />Shipment Applicable Permit Numbers: <br />Hauler: Req# <br />n <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />Date /Z <br />Phone #: <br />Applicable Penn it Numbers: <br />Date <br />e. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone C <br />Applicable Pemat Numbers: <br />ru <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />'NDICATION <br />Transferrw c.. ,r. 1 cu [: to North Sak Lake, <br />y—F71 <br />BA.Oesignated Facility: <br />J <br />SuKkIme,Im. <br />4 <br />4135 W. St <br />u- <br />Frasno.CA 93722 <br />w <br />(559} 27s-1121 <br />TSADST22 <br />ire <br />e8. Attsmate Facility: <br />U SC, Atternate Facility: <br />U 80. Alternate Fadltty: <br />Inc. <br />steirkyCte, hx. <br />steikycia, hC. <br />90 North 1100 West <br />30542 San Antonio Strad <br />2775 E. 26th St, <br />North Sada Lader. Ur 84054 <br />Naytrvard, CA 94544 <br />Vernon, Cao 90056 <br />(001) 1555 <br />(510)552-2177 <br />(0392-3= <br />3A 44t3%W36 <br />TS3iJT <br />TSKW 26 <br />that I have been authorized by the applicable state agency to accept untreated medical Wastes and that I have <br />tes in aocordance With the requirement outlined in that authorization. <br />WE <br />ra <br />