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DILA! WASTE TRACKING FORM NUMBER <br />-- ® STANDARD MANIFEST 0e1•to-05-STA <br />08 Stericycle IN of EMERGENCY CONTACT- cNEMTREc t -600-42443M RNO. <br />MDFROOCF2D <br />0 , Route #: 301 - T CUSTaMF�t No. 21132 <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />GOLMN LIVING flYPANA - 569 <br />4545 SHELLEY COURT <br />STOCK ON, CA 95201 <br />CUSS& ER Num b <br />2A. REsCRIPMON OF WASTE <br />UN3291, Regulated Medical Waste, N <br />6.2, PGII <br />UN3291, Regulated Medical Waste, l <br />62. PGII <br />CC 11113291, Regulated Medical Waste. <br />® 6.2, PGII <br />Q UN3291, Regulated Medical Waste, <br />6.2, PGII <br />W UN3291, Regulated Medical Waste, <br />Z 6.2, PGII <br />W UN3291. Regulated Medical Waste, <br />6.2. PGII <br />UN3291. Regulated Medical Waste. <br />6.2, PGII <br />11143291. Reaulated Medical Waste, <br />illillimillilillillillluliflu <br />(209) 477-0271 <br />GOGRATo Ws REGISTRAT" t <br />UNERTYPE <br />8857 - 90 Gal Tub (Bio) (1Z Cu ft) <br />T849 - 37 Gal Tub (Bio) (4.9 Cu 'Et) <br />1'914 - 44 Gal Tub(Bio) (5.9 Cu ft) <br />T921 - 20 Gal Tub(Bia) (2.7 cu ft) <br />?815 - 20 Gal Tub (Path) (2.7 cu tt.) <br />Ty15 - 20 Gal Tub (Chemo) 12-7 cu ft) <br />6/6/2012 <br />C. NO. OF 12D. VOLUME <br />CONTAINERS <br />6.2, PGII <br />3. Generator's Certification: '1 hereby declare that the contents of is consignment are fully and accurately <br />TOTALS !.� <br />described above by the Proper shipping name and aro dassitied, paged. marled and labelled/placarded, and <br />are in all respects in Proper condition for transport aocordiing to applicable international and national governmental regulatioW <br />!/ A <br />Printedfr ed Norma ®"' stgnaru <br />14. TRANSPORTER t AODREss:This is a <br />Stecicwle, Inc. 4135 W. Swift St <br />FCesno,CA 93122 <br />a TRANSPORTER CERTIFICATION: <br />Receipt of medical waste as described abOV0. <br />Printrrype Name �/n V ° ® Signature <br />a nnn'=FDIATE HANDLER 2 i TRANSPORTER 2 ADDRESS: <br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Printrrvoa Name Signature <br />ff.Q_ Ca <br />It <br />Phonelt: (559)278• <br />Applicata Permit Numbers: <br />Hauler Reg# <br />Date <br />Phone p: <br />Applicable Permit Numbers: <br />Date — <br />a] <br />Flt <br />a <br />AUTOCLAVE l <br />LU TRE Ill iii TIZenity th t i have been authorized by the applicable state agency to accept untreated medical Wastes and that have <br />received the above indicated wasteE in accordance With the requirement outlined in that authorization. <br />Signature Date <br />Prim e <br />ORIGINAL <br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phunts w; <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt <br />of medical waste as described above. <br />- <br />Print/Type Name <br />Signature <br />Date <br />7. DISCREPANCY INDICATION <br />cu A to : NWM SA Lab, <br />U f <br />TruiShMd' <br />aB Aftmate Faddty: <br />$C. Facttity. <br />8AANtemate Facility: <br />. <br />�- <br />J <br />aA.ont9nated Facility: <br />tnc. <br />cY6le. Inc.Stelic <br />e, Inc. <br />2775 E. 26M St <br />a <br />. Inc. <br />4`195 W. St <br />4100 <br />30542 Sen Street <br />HoW4ard. CA 94544 <br />Vernon. CA 90058 <br />Fress} o.0 <br />N <br />-1L • UT 84054 <br />(510) 562-2177 <br />(323) 362-30M <br />T 26 <br />w <br />1921= <br />(SMrarnerr�in <br />(fit <br />14.36 <br />TS31 <br />TSJt)S <br />a <br />AUTOCLAVE l <br />LU TRE Ill iii TIZenity th t i have been authorized by the applicable state agency to accept untreated medical Wastes and that have <br />received the above indicated wasteE in accordance With the requirement outlined in that authorization. <br />Signature Date <br />Prim e <br />ORIGINAL <br />