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MEDICAL WASTE TRACKING FORM NUMBER <br />ssi Stericycie IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-000.42443011 sTAt+aeRo MAwtFFss 001 -10 -06 -SM <br />P% h"I.- smc Route S: 301 - S CUSTOMER NO. 21132 KDFRO00040 <br />1. Generator's Name, Address and Telephone Number <br />ATTN : <br />GOLriB'15i LIVING HYPAMk - 569 <br />4545 SESLLEY COURT <br />STOCKTO11, CA 95207 <br />1111111110111 OHIO 11111 Nil <br />(209) 477-0271 <br />5/23/2012 <br />Cusmom Nuuestl 6080856-001 GOWEPATO" REGtSMTM It <br />2A. DESCRIPTION OF WASTE 2a. CONTAINER TYPE 2C. NO.OF2D. VOLUME <br />UN3291. Regulated Medical Waste. 3-0-S., TB57 - 90 Gal Tub (Rio) (],2 cu ft) CONTAINERS <br />6.2, PGII a Ff. <br />uiu"I, Regulated Medical waste, n.o.s., TH44 - 37 Gil Tub (Rio) (4. cu t <br />6.2, PGII <br />® UN3�I' Regulated Medical Waste, n.os. T814 - 4 Cu <br />tt <br />62, Q UN3291, Regulated Medical Waste, n.os , <br />6.2. PGO <br />W UN3291, Regulated Medical Waste, n.o s.. TB - Ga a CU <br />I+ZZ 6.2, PGII <br />s u Wan <br />Regulated Medical ste, .o.sem <br />., rY15 - 20 Gal Tub (Chemo) (2.7 cu <br />UN329t, Regulated Medical Waste, n.o.s.. <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.os., <br />Pharmaceutical Waste <br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are "and accurately I TOTALS 0 - <br />described above by the proper shipping name, and are classified, packaged. marked and labeled/placarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations" <br />,Printed(Typed Name �' �-+ Signature <br />i w 4. TRANSPORTERIA!]L]ReECiGjjCle, Inc. ® 1't1i3 13 a Thro Shipm t <br />y 4135 V. Swift St <br />O rreano,CA 93722 <br />Re a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />i <br />Print/Type Name fL v. Signature <br />S. INTERMEDIATE HANDLER 2ITRANSPORTER 2 ADDRESS: <br />N y� <br />iINTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />I <br />f PrinVType Name Signature <br />n, 6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: <br />w <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdnVType Name Signature <br />G. 1 1/ 1t7 Cu Ft. <br />41 Date la <br />Phone lt: <br />"pler Regi <br />Date mei ® Z <br />Phone a: <br />Applicable Permit Numbers: <br />Date <br />Phone e: <br />Applicable Permit Numbers: <br />Date <br />t. DISCREPANCY INDICATION TrMfIltned Cardal"i8, cu Q to : Nwth Sat Lake, U° <br />IA. Deslgneted Facility: <br />88. Alternate Faetilty: <br />Inc. <br />® SC. Alternate FaeiOty: <br />. Inc. <br />U 80. Altem24e Faclft: <br />Inc. <br />SwItcycie, ft. <br />4135 W. St <br />90 North 1100 West <br />30542 San Antonio <br />2776 .26th St <br />Fnesnta.CA 93722 <br />North Salt Lake, UT 84054 <br />Hayward, CA 94544 <br />Vernon, CA 90058 <br />(558) 275-1121 <br />(801)MIM <br />(510) 562-2177 <br />1323) 362-30D0 <br />3A 448,JA-38 <br />TS3irrS <br />T3/OST 26 <br />aDALE ANNE ORTIZ <br />W TREATMENT FACILITY: I certify <br />tr <br />re iveMa reed was <br />Prue' Name <br />lwil <br />I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />1 accordance with the requirement outlined in that authorization. <br />Signature — Date <br />