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-- — MEDICAL WASTE TRACKING FORM NUMBER +. Stericyde' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1410042 STANDARD MANIFEST tat-taas-sM • ^ ° Route 301 - 16 CUSTOMER No. 21132 HDIFR00CI OT 1. Generator's Name, Address and Telephone Number A`> TN GOLDEN L 1IG ELYPASk - 569 4545 5111M EY COURT S T1, CA 95207 oiioieiioo�umo��ieu�ia'ooau (209) 477-0271 Regulated 6/27/2012 2C. NO. OF 20. VOLUME CONTAINERS - 11,45 — ► 3. Generator's Certification: ation: i hereby declare that the contents at oris consignment are fully and accurately �® described above by the proper shipping nam and are classified, packaged, marked and labegedtplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations." &� Printed/T ped Name O (41 1 e Z -Signature " l I s 6 Cu Ft, Phone 4. TRANSPORTER i ADDRESS: (55y) r0 Cc Stecicycle, Inc. This is a ugh ShipmentApplicable Permit Numbers: 4135 V. Swift St Fce;ano,CA 93722 va p� d TRANSPORTER CERTIFICATION: Receipt of metGtxl waste as described above. PrinMpe Name =Ani1/ Signature 5 INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: n� INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. PrinVTWM Name Signature Hauler R&O Date Phone 4: Applicable Permit Numbers: Date R S. INTERMEDIATE HANDLER 3 t TRANSPORTER 3 ADDRESS: Phone e' Applicable Permit Numbers: I INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of metl+caI wastaas described above. Printlrvtta Name Signature Date 7. DISCREPANCY INDICATION 'f ou a e , UT s &L Designated Facility' Inc. -j If SWICyde. I C� 4135 W. 9ANk St (5U) 27S-1121 TSt4SM ae. Alternate Facility* Swicycle. C. g0 Nam /1OU West NoM SO L a W, LIT 840541 (8(tt) s3$-Im 34448%W36 iH' .l II. tic r ^:v • ru,.,s x +cru •.c TREATMEMTTFACFLtTY: !certify that have been authorized by the appftcatrle state agency to accept untreated medical Wastes and that M have receivv�7-ihFabbsidgh(rtcaterirwastes r')1 accordance With the requirement ®uUined in that authorization. ORIGIRIAL. 608 08 56 -001 G> NrRAM s REGIShUTION f 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE UN3291, Regulated Medical Waste,n.O.s.. 1857 - 90 Gal Sub (Rio) (12 Cel ft) 6.2. PGII UNMI. Regulated Medical Waste, a.O.s.. T849 - 37 Gal Tub (Rio) (4.9 Cu ft) 6.2. PGII CC Wa. n.o.s., UACf29t, Regulated Medicalste T814 - 44 Gal Tub (sic► (5-9 Cu ft) Q 6.2. PGI! UN3291. Regulated Medical Waste, FLU,, T821 - 20 tial Tub( i o) (2.7 Cu ft) it6.2. PGII LU UN3211. Regulated Medical Waste. e.o.s.. x825 - 20 gal Tub (Path) (2.7 Cu ft) Z 6.2. PGII us �6.2. UN=l, Regulated Medical Waste. n.o.s.. - 20 eel Sub (Chemo) (2.7 Cu ft) PGII ttN3291. Reautateil Medical Wash, n.o.s., Regulated 6/27/2012 2C. NO. OF 20. VOLUME CONTAINERS - 11,45 — ► 3. Generator's Certification: ation: i hereby declare that the contents at oris consignment are fully and accurately �® described above by the proper shipping nam and are classified, packaged, marked and labegedtplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations." &� Printed/T ped Name O (41 1 e Z -Signature " l I s 6 Cu Ft, Phone 4. TRANSPORTER i ADDRESS: (55y) r0 Cc Stecicycle, Inc. This is a ugh ShipmentApplicable Permit Numbers: 4135 V. Swift St Fce;ano,CA 93722 va p� d TRANSPORTER CERTIFICATION: Receipt of metGtxl waste as described above. PrinMpe Name =Ani1/ Signature 5 INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: n� INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. PrinVTWM Name Signature Hauler R&O Date Phone 4: Applicable Permit Numbers: Date R S. INTERMEDIATE HANDLER 3 t TRANSPORTER 3 ADDRESS: Phone e' Applicable Permit Numbers: I INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of metl+caI wastaas described above. Printlrvtta Name Signature Date 7. DISCREPANCY INDICATION 'f ou a e , UT s &L Designated Facility' Inc. -j If SWICyde. I C� 4135 W. 9ANk St (5U) 27S-1121 TSt4SM ae. Alternate Facility* Swicycle. C. g0 Nam /1OU West NoM SO L a W, LIT 840541 (8(tt) s3$-Im 34448%W36 iH' .l II. tic r ^:v • ru,.,s x +cru •.c TREATMEMTTFACFLtTY: !certify that have been authorized by the appftcatrle state agency to accept untreated medical Wastes and that M have receivv�7-ihFabbsidgh(rtcaterirwastes r')1 accordance With the requirement ®uUined in that authorization. ORIGIRIAL.