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MEDICAL WASTE TRACKING FORM NUMBER <br />i ® Stericycle' IN CASE OF EMERGENCY CONTACT: CMEMTREC 1-8004249304 STANDARD MAWEST 001 -10 -MSM <br />®•® , ", Route #: 301 -- 3 CUSTOMER NO. 21132 HDFROOCH23 <br />ORIGINAL <br />1. Generator's Name, Address and Telephone Number IIIIIIIII I I II I milinj <br />AWN: M I 11111111 <br />GOLMM LIVING HTPAi1A — 569 <br />4545 SHELLET COURT <br />swmom, tom► 95207 <br />(209) 477-0271 6/20/2012 <br />CUSTOMER Nu>Se 6080956-001 REwTnAT1er1 r <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NEL OF <br />2D. VOLUME <br />103291, Regulated Medical Waste. mo.s_, <br />TH57 - 90 Gal Tub (Rio) (12 cu ft) <br />CONTAINERS <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.os., <br />TB49 - 37 Gal Tub (Rio) (4.9 cu ft) <br />62, PGII <br />Cu Ft. <br />Regulated Medical Waste, mos., <br />TB14 - 44 Gal Tub(Bio) (5.9 tv ft) <br />� <br />C <br />®UN3291. <br />6.2, PGII <br />•7 Cu Ft. <br />Q <br />UN3291, Regulated Medical Waste nos., <br />'� - a o Cx: <br />Cr <br />62, PG,, <br />Cu Ft. <br />W <br />UN3291, Regulated Medical waste. rt.os., <br />T815 - 20 Gal Tub (Path) (2.7 eu ft)W <br />6.2. PGl1 <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.os., <br />7Y15 - 20 Gal Tub (Chem*) (2.7 Cu ft) <br />62. PGII <br />Cu Ft. i <br />U143291, Regulated Medical Waste, n.os.. <br />fi2. PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, mos., <br />6.2, PGII <br />Cu Ft. <br />PharmacetitiCal IdaStR <br />Cu Ft. <br />3. Generator's Cerlflcalon: I hereby declare that the contents of this consignment are fully and accurately TOTALS ® <br />described above by the proper shipping name, and are classified, packaged, marked and tabeiRK iara;rded, and <br />are in all respects in proper condition fortransporttransport according to applicable iinte-rrnatloml and national governmental reguildons." ! . <br />, <br />V� "" !2 <br />Printed/Typed Name `�" ' Signature "Date <br />4. TRANSPORTER 1 ADDRESS:) s: - <br />Stericyrle, Inc.. ® This is a O h ShipmentphoneApplicatyePermpNumbers <br />4135 V. Swift St Haulee Retg# <br />Z a <br />Fcerano,CA 93722 <br />N <br />a a <br />TRANSPORTER CERTIFICATION: Rweipt of medical waste as described above. 0 <br />►¢-249 <br />PrinVlype Name/ 1f/ • _ _ Signature Date J2 <br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone K: <br />cc <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinVType Nanta Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone e: ; <br />4 ¢ <br />Applicable Permit Numbers: <br />w <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrInVType Name Signature Date <br />7. DISCREPANCY INDICATION <br />Tranfened containers, cu 0 to : North Sal Lake, UT <br />8A. Designetod Facility: 88. ANemate Faciliry: Q 8C. ARsmate Facility: aD. Anomake Facility: <br />J Sbarrtcycle, Inc. StIfflCycle. Inc. Stericycle. Inc. Serf Inc. <br />(j 4135 W. SWtIt St so i t00 West 30542 Stet 2775E 213 SL <br />4 Fresno.CA 93722 North Salt Lake. UT 84M Hqward, CA 94W Vernon. CA XII <br />(539) 275-1121 (80 1) 9136.1535 (6 10) 552 2177 1323) 362-3= <br />� TSIOST22 3AA48-JA-36 TS31RSl0ST25 TWOST 26 <br />IAUTOCLAVE <br />� TREW tQ�AT&rtify th t I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />4— received the above indicated wastes in accordance With the requirement outlined in that authorization. <br />Nwryp.0 2 0 Z 01 Z Signature Date <br />I <br />ORIGINAL <br />