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��— MEDICAL WASTE TRACKING FORM NUMBER <br />!® *! StericydW IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-1 424 -WW STANDARD MAMFEST 001.1045 -STD <br />^w rro <br />Route 3101 - CUSTOMER No.21432 M[�ROOt:BSi <br />� _ _'w ORIGINAL <br />1. Generator's Name, Address and Telephone Number INN <br />AWN,. I Bill III I <br />WLM LIVING EMAM - 569 <br />4545 SHZLLET COURT <br />S'I'OCKT011, CA 95207 <br />(209) 477-0271 5/9/2012 <br />CusmrsERNLMER 6080856-001 G€NmtAtowsAcGw Twm# <br />2A. DESCRIPTION OF WASTE <br />20. CONTAINER TYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3291, Regulated Medial Waste, mos., <br />6.2, PGII <br />TB37 - 90 Gal Tub (Bio) (12 cru ft) <br />CONTAINERS <br />Cu FL <br />UN3291, Regulated Medical Waste, MOS., <br />6.2, PGII <br />T849 - 37 Gal Tub {Bio} (4.9 Cu it) <br />Cu Ft. <br />M <br />UN3291. Regulated Medial Waste, n.o.s., <br />TD14 - 44 Gal Tub (Bio} (5.9 Cu it) <br />Cu Ft. <br />6.2, PGII <br />&® <br />Q <br />UN3291, Regulated Medical Waste. n.o.s.. <br />TO21 - 20 Gal Tub (Bio) (2.7 cu ft) <br />6.2, PGiI <br />Cu Ft. <br />W <br />Z <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />gB15 - 20 6a1 ?tfb (cath) (2.7 Cu it) <br />Cu Ft. <br />lJU <br />UN3291 Regulated Medical Waste, n.0 -S., <br />6.2, PGII <br />TY15 - 20 Gal Tub (Chemo) (2.7 cu ft) <br />Cu Ft. <br />UN3291, Regulated Medical Waste, mos., <br />6.2. PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PG If <br />Cu Ft. <br />Nance <br />Cu Ft. <br />41maaav"46 <br />Q <br />3. Generstor s Certification: 'I hereby declare that the contents of this consignment are fully and accurately TOTALS 10 t $ . i Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelleclIplacardlecf and <br />are in all respects in proper condition for transport according to ' bia international and national govern ntal regula <br />'X S k-ja <br />Print ped Name nature Date <br />4. TRANSPORTER 1 ADDRESS: I V I V Phone e: (559)27e-6994 <br />StecioWle, Inc. 0 This is a Through ShipzentAppticablePermitN <br />4135 V. Swift St Hauler <br />g <br />Fceeno,CA 93722 <br />Oz. a <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />roma. <br />Print/Type Name Gy r Signature Date <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone k: <br />+�+ <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone k: <br />w <br />Appiicabte Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />I.I. t ft to: MCF01 Sd Lah, UT <br />--ft 8C. Arnate F killty aD. Alternate Facility: <br />SA Deelgnetsd Facility:tiB. Alternate FecH_Aft <br />Im. <br />3 <br />sterkyde. Inc. Slerkyds. MC. Inc. <br />4135 W. St 1100 2 Salt 2775 , 26th Sic <br />FreSnOCA 83722 North Sd Ltdoa, LIT SM Hrovard, CA 34544 velmorl, CA game <br />w(510) <br />) 275-1121 (801) 1355 �St�j S82 2177 (323) 362 -MM <br />3A44644.36 TS311tiSIOSM -26 <br />g <br />alaAVE <br />�{ (p} { <br />TRE kG�ITYR i Icertity the k have been authorized by the applicable state agency to accept untreated medical wastes and that k have <br />FQ- <br />recelved the above Indicated wastes accordance with the requirement outlined in that authorization. <br />09 <br />P, Signature Date <br />� _ _'w ORIGINAL <br />