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MEDICAL WASTE TRACKING FORM NUMBER <br />®• Stericycle' IN CASE OF EMERGENCY C ACT: CHEMT'REC 1.880.421-9300 STANWO MANIFEST Itd1.104"M <br />• ^*� .� Route 0�: 301 - CUSTOMER NO.21132 MDFROOSVPY <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />GOLDEN LIVING HYPAXA - 569 <br />4545 SBELLEY COURT <br />simlMs, CA 95207 <br />(209) 477-0271 <br />CUSTOMER NUMBER 6080856-001 GWERAsturs REGISTRATM # <br />1 2A. DESCRIPTION OF WASTE 29. CONTAINER TYPE 2C. NO. OF <br />UNMI. Regulated Medial waste. mas., T1351 - 90 Gal Tub (Bio) (12 cu ft) CONTAINERS <br />' 6.2, PGII <br />UNMI1 <br />CC UN3291. <br />0 6.2,'PGII <br />Q UAKt291, <br />&2. PGII <br />W UN329t, <br />Z 6.2, PGII <br />ull UhK329t. <br />Medial Wane. n.os., T849 - 37 Gal Tub (Bio) (4.9 cu ft) <br />Medical waste, mo.s.. TB14 - 44 Gal Tub(Bio) (5.9 Cu ft) <br />Medial Waste, n.o s..l T1321 - <br />waste, n.os..I T915 - 20 Gal Tub (Path) (2.7 Cu ft) <br />Waste, n.as. T'Y15 - 20 Gal tub (Chrmo) (2.7 cu ft) <br />UN3291Regulated Medical Waste. <br />6.2, PGIi <br />Pharmaceutical <br />1/19/201'2 <br />VOLUME <br />so <br />3. rector's on:'I hereby declare that the contents of this consignment are fully and accurately I TOTALS IIII • 9 <br />described above by the proper shipping name, and are classified, packaged, marked and labelledtplacardad, and <br />are in all (aspects in proper conditiat for transport acoording to applicable International and national governmental regutalions! <br />:VJq'a /n�M1 {{ ¢ �/J,, <br />, Print <br />\1 Z t�, l� c� 2 f g l/ @ •2 -Signature. i/// v _"• Date , %a /�• <br />a.TRANSPORTER t ADDRESS: <br />Inc. This is a Th h Shi enter ®a. <br />S 135 Scast ❑ � lI.N. Permit Numbers: <br />d135 t Swift Ave. Hauler Reg# 3400 <br />g Fresno,Ca 93722 <br />oM a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />cc OPWP) <br />t- PrinUTyps Name '� V, ra` Signature <br />Date . 1#16A 6 <br />5. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of mod" waste as described abare. <br />Print/Type Name Signature <br />Phone #: <br />Applicable Permit Numbers: <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />as <br />Applicable Permit Numbers. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of meftal waste as described above. <br />PrinVTWm Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />fxJ Q to : Naft Saft bdoe, <br />UT <br />8A. DesignatedFeNlity: 88. A Fealty 8C. Alternew Fact ft: <br />80. AlMnuts FwAl4: <br />Inc Ino- Incineration StedcM Inc-A <br />Inc - <br />t� <br />4135W.SWFTAVE M NORTH 1 IWVYEST 1346 C <br />2776 E 2667H <br />4C <br />FRESNO,CA 93722 NORTH SALT LAKE CITY. u r San Laanft, CA 94577 <br />VERNON. CA MM <br />(569)276-1121 (801) -1655 (510)562- 2177 <br />(323) 362 - 30M <br />TSIOSTM TS311TWO. <br />-26 <br />. .._. .� .a7 <br />us TREATMENT FACILITY: I Certify that I have been authorized by the applicable state agency to accept untreated medical Wastes and that I have <br />u <br />received the above indicated wastes in accordance With the requirement outlined In that authorization. <br />Nntfr Na JQ 1 2017 Signature <br />Data <br />