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EDICAL WASTE TRACKING FORM NUMBER Stericycle' IN CASE OF EMERGENCY CONTACT: CHENTREC 1.800.424.9300STANDARD ► FEST cot• so STD <0010 ► ',r.. -I ' I" Route 0: 301 - 6 CUSTDMER NO. 21132 MDFROOCE2A t. Generator's Name, Address and Telephone Number ATTN GOLDEN LIVIi16 RTPAII]k - 569 4545 SHELLEY COURT STCCKmN, CA 95207 11111n1pir,omo�aouooii�mm (209) 477-0271 5/30/2012 2C. N0. OF 20- VOLUME CONTAINERS L+ �f• u P ALX 0 °' 300, p .3 3. Generator's Certification: '1 hereby declare that the contents of this consignment are fully and accurately TOTALS described above by the Proper shoptng name, and are dasslru®d, pqrka9iid� marked and Iat*19d/piacarded. and are in all respects in proper condition for transport according to applicable international and national governmental ragutatkms' PrirdedrTyped Name K RE 4% e Z Signature Date Phone 8: (559)215 4. TRANSPORTER t ADDRESS: This i3 a gh Shipment Stericycle, Inc. Applicable Permit Numbers : 4135 W. Swift St: Hauler Reel# a� g Preano,CA 93722 CL C TRANSPORTER CERTIFICATION:)JReceipt: c4 medical waste as abaft 11 1(-..0 — -- f PdnUTypa Name V. Signature B. INTERMEDIATE HANDIER 2 f TRANSPORTER 2 ADDRESS: H� INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Printffvoe Name _ Signature e. INTERMEDIATE HANDIER 3 /TRANSPORTER 3 ADDRESS: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Fiecelpt of medical waste as described above. a.i„ rrTya Name Signature Date 3 02 Phone e: Appticsbte Pemtit Numbers: Date nww .- Applicable Permit Numbers'. Date T. 1ptEPANCY INDICATIONT KT>3� �„ � , p W ft to : North Sat Lake, tff Designated rocfitgrc 80. Alternate Fae8lty. 6080856-001 Gacmun"ReCUSTRAIMS a ®H Q W 2 2A. DESCRurnoN OF WASTE UN3'291, Regulated Medical Waste. a.es., 6.2. PGIi :W• CONTAINER TYPE 4857 - 90 Gal Tub (Bio) (12 Cu Lt) T649 - 37 Gal Tub ((iia) (4.9 Ctii ft) UN3291, Regulated MedwWaste, o.O.s., 6.2, PGII UN329i. Regulated Me" Waste. 4.0.s., 6.2. PGII TB14 - 44 Gal Tub (Dio) (5-9 Cu it) 1 - 24 Gal Tub(8io) (2.CU tet) 7827 UN. Regulated Medical Waste, a.o.s.. 6.2, Pill TRIS - 20 Gal Tub (path) (2.7 Cu ft) UNMI Regulated Medial Waste, n.os.. 6.2, PGli TY1S - 20 Gal Tub (ChemO) 42.7 cu ft) UN3291 Regulated Medical Waste.a.os., 6.2, PGII itNV91. Regulated Medical Waste. ao.$.. 5/30/2012 2C. N0. OF 20- VOLUME CONTAINERS L+ �f• u P ALX 0 °' 300, p .3 3. Generator's Certification: '1 hereby declare that the contents of this consignment are fully and accurately TOTALS described above by the Proper shoptng name, and are dasslru®d, pqrka9iid� marked and Iat*19d/piacarded. and are in all respects in proper condition for transport according to applicable international and national governmental ragutatkms' PrirdedrTyped Name K RE 4% e Z Signature Date Phone 8: (559)215 4. TRANSPORTER t ADDRESS: This i3 a gh Shipment Stericycle, Inc. Applicable Permit Numbers : 4135 W. Swift St: Hauler Reel# a� g Preano,CA 93722 CL C TRANSPORTER CERTIFICATION:)JReceipt: c4 medical waste as abaft 11 1(-..0 — -- f PdnUTypa Name V. Signature B. INTERMEDIATE HANDIER 2 f TRANSPORTER 2 ADDRESS: H� INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Printffvoe Name _ Signature e. INTERMEDIATE HANDIER 3 /TRANSPORTER 3 ADDRESS: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Fiecelpt of medical waste as described above. a.i„ rrTya Name Signature Date 3 02 Phone e: Appticsbte Pemtit Numbers: Date nww .- Applicable Permit Numbers'. Date T. 1ptEPANCY INDICATIONT KT>3� �„ � , p W ft to : North Sat Lake, tff Designated rocfitgrc 80. Alternate Fae8lty. BC. ArmyM to Facility: Skericyct$, Inc. L.i 8D. Attune» facaury: Swcycle, Inc. St9rlt11de.1nC. slericyrJe. W. 4136 W. SYdtt St 9U mom 1100 West 30544 San AnWft Street CA 94544 2775 E. 2SOT St Vumon, CA SIM Fresno.CA NOM Salt Lalfa. UT 84454 (80{j 36.1555 (510) 55Z-2177 (M) 275-t t21 tetA�T"72 31A 446,{A-36 TS31/T91/OST2S TS(OS6T-26 3�0326 aowF-F AUTOCLAVE R ethe above indicated watiac=cordance t 4 f 0 by the appdcabte state agency to accept untreated medical wastes and that I have the requirement outlined In that authorization. Date Cu FI.