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MEDICAL WASTE TRACKING FORM NUMBER ®®, Stericycle• IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800424-93M STANWD MANIFEST 001'10-oe'STD Route f: 301 — 14 CUSTOMER NO. 211321 1. Generator's Name, Address and Telephone Number ARTN GOLM LM7IG EMARA - 569 4545 SH3E'LLEY COURT STocK70,N, CA 95207 (209) 477-0271 6/13/2012 6.2, PGII UNMIi Regulated Medias Medical Waste. mas.. UN3291, Regulated Medial Waste, n.o.s., 6.2. PGII 3. Generator's Certlfkation: "1 hereby declare that the contents of this consignment are fury and accurately [ TOTALS IN, described. above by the proper shipping name, and are clessifled, packaged, marked and tabelled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations' i Printedinyped Name C (z 0 Z 4 V t Z' Signature Date 411311 Z 4. TRANSPORTER 1 ADDRESS: Phone #: W Stecicyycle, Inc. 'I9siei is a ugh Shi�entappllcanfe Permit Numbers: s 4135 E. Swift St Hauler a BCesno,Ch 93722 v> 4 TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. a Print/Type Name • ` 'j� J�""Yxl. Signature® 5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #: N Applicable Permit Numbers: i INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature Date U1 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone115 ta: Applicable Permit Numbers: 3 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. '= Printfrype Name Signature Date T. DISCATION REPANCY INDIC co ou it to , UT r /r J , I�M�Iti.. iriclir`ww i Iia. Alternate Feclllty: it.-. 90 NM1h 1100 North S& .lit (804) SWI S55 31A.4 36 6C. Attarraft Facility: irm. 30542 SST Ajtwft Sb" Hirowwd. Sam (Stix) SZ -2177 TS31AWIST25 that have been authorized by the applicable state agency to accept untreated medical wastes and that I have les 1 accordance with the requirement outlined in that authorization. �i�ta Date CUSTOUIR auMaa„ 6080856-001 GraitATo"FIEGAMT"# 2A. DESCRIPTION OF WASTE 2e. CONTAINER TYPE 2C. NO. OF 2D. VOLUME UN3291. Regulated Medical Waste, n.o.s..CONTAINERS T857 - 9Q t3a1 Tub (trio) (12 cru ft) Cu Ft. 6.2. PGII UN3291, Regulated MedM Waste, a.os.. 4849 - 37 Gal Tub (Bio) (4.9 cu tt) Cu Ft 6.2. PGII CC UN3291. Regulated Medical Waste, o.o.s.. 2814 - 44 Gal Tub (bio) (5.9 Cu tt) PGII . Cu Ft O6.2, 44 UN329i Regulated Medical Waste, o.os.. o • , cu t Cu Ft. fi 2, PGII W UN3291. Regulated Medial Waste, n.o.s.. 5615 - 20 Gal Tub (Path) (2.7 cu ft) Z 6.2, PGII Cu Ft W i9 l UN1: eguateedial Waste. rr o.s.. 329 R d M IY25 - 20 eel Tub (Chrtsao) {2.7 Cu ft} r Cr 6.2, PGII UNMIi Regulated Medias Medical Waste. mas.. UN3291, Regulated Medial Waste, n.o.s., 6.2. PGII 3. Generator's Certlfkation: "1 hereby declare that the contents of this consignment are fury and accurately [ TOTALS IN, described. above by the proper shipping name, and are clessifled, packaged, marked and tabelled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations' i Printedinyped Name C (z 0 Z 4 V t Z' Signature Date 411311 Z 4. TRANSPORTER 1 ADDRESS: Phone #: W Stecicyycle, Inc. 'I9siei is a ugh Shi�entappllcanfe Permit Numbers: s 4135 E. Swift St Hauler a BCesno,Ch 93722 v> 4 TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. a Print/Type Name • ` 'j� J�""Yxl. Signature® 5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #: N Applicable Permit Numbers: i INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature Date U1 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone115 ta: Applicable Permit Numbers: 3 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. '= Printfrype Name Signature Date T. DISCATION REPANCY INDIC co ou it to , UT r /r J , I�M�Iti.. iriclir`ww i Iia. Alternate Feclllty: it.-. 90 NM1h 1100 North S& .lit (804) SWI S55 31A.4 36 6C. Attarraft Facility: irm. 30542 SST Ajtwft Sb" Hirowwd. Sam (Stix) SZ -2177 TS31AWIST25 that have been authorized by the applicable state agency to accept untreated medical wastes and that I have les 1 accordance with the requirement outlined in that authorization. �i�ta Date