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—� MEDICAL WASTE TRACKING FORM NUMB ER i® Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.8004244M STANDAROMANIFEST 001.1 ,MSTO ° ftmahe' ft"b ''°*.*°°° CUSTOMER NO. 21132 A.aute-5-' 'tA t_ d MOFRQQ$LIRX t. Generators Name, Address and Telephone Number AT TN GOLDEN LIVING HYPANA - 569 4545 SHELLEY C01= STOCKTON, CA 95207 6.2, GOMUTOFM REIbSTR "W R CONTAINER TYPE nV — 41 Ual TMR tOSO) 11.11 CU LL) TB14 - 44 Gal Tub(Bio) (5.9 cu tt) T921 - 20 Gal Tub(Bio) (2.7 cu ft) T825 - 20 Gal Tub (Path) (2.7 cu it) 7 Cu o�u .C. No. 2D. VOLUME CONTAINERS Cu FL t /� Cu FL 2 l ` L7 Cu Ft. CUSTO M Nuawrt f I 2 I � F � 8 Cu Ft. Date 1111112- f/ 1Z.4. r 2A. DESCRIPTION OF WASTE 4. TRANSPORTER 1 ADDRESS: UN32tit, Requtaud Medical Waste, 6.2, PGII Slencyde Inc -Aukickwill 4135 W. WAFT AVE FRESNO.CA 93722 (552)275-1121 UN3291, Regulated Medical Wase, 52, PGII M 6 2. PGI. Regulated Medical Waste. Q lZ W W UN3291. Regulated Medical Wane. 62, PGII UN3291, Regulated Medd Waste, 6.2. PGII UN3291. Regulated Medical Waste, 62, PGII -26 UN3291 Regulated Medical Waste, 6.2. PGII 6.2, GOMUTOFM REIbSTR "W R CONTAINER TYPE nV — 41 Ual TMR tOSO) 11.11 CU LL) TB14 - 44 Gal Tub(Bio) (5.9 cu tt) T921 - 20 Gal Tub(Bio) (2.7 cu ft) T825 - 20 Gal Tub (Path) (2.7 cu it) 7 Cu o�u .C. No. 2D. VOLUME CONTAINERS Cu FL t /� Cu FL 2 l ` L7 Cu Ft. `n G. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: ON (esu, INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as deecribed above. a Pdnt(Type Name Signature 7. DISCREPANCY INDICATION Phone C Applicable Permit Numbers: Date I 3. Generator's Certification: I hereby declare that the contents of this consignmeM are tufty and accurately TOTALS 1" described above by the proper shipping nam, and are classified, packaged, marked and labeltedtplacarded. an are in all respects in proper condition for transport according to applicable international and national governmen regutatfons7 i I Printed(T Name Y)DmraSignature I 2 I � F � 8 Cu Ft. Date 1111112- f/ 1Z.4. U 9C. Alternate Facility: 4. TRANSPORTER 1 ADDRESS: ne a: (559) 275-11 i Slencyde Inc -Aukickwill 4135 W. WAFT AVE FRESNO.CA 93722 (552)275-1121 Stericycle, Inc. This is a gh Shipment Applicwe r: <0 4135 Rest Swift Ave_ Bauler 9 3400 2% Fresno,Ca 93722 -26 If Z TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. t q� � "� Y amu- Print/Type Name Sigrtature Dare 6. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone # Applicable Permit Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print(Type Name Signature Date `n G. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: ON (esu, INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as deecribed above. a Pdnt(Type Name Signature 7. DISCREPANCY INDICATION Phone C Applicable Permit Numbers: Date I i tiA. [>ealgneted Facility: U aB. Alternate Facigty: U 9C. Alternate Facility: D 90. Attamate Facility: a tom, Slencyde Inc -Aukickwill 4135 W. WAFT AVE FRESNO.CA 93722 (552)275-1121 Ino- Inchwillon 90 NORTH 1100 WEST NORTH SALT LAKE CITY, U1 ( 1) SbwtcVde Inc -Aulochm 1345 Doom cony S4e C Sart LA o. CA 94577 (SIC)SO-2177 Inc 2775 E 215TH STREET VERNON.CA WIM (=M -MM a NNE ®A til I -36 6. M1 Z9 -26 ¢ F- TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have received the above indicated wastes in accordance with the requirement outlined in that authorization. PrinVT 8AN 112012 Signature Date i