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MEDICAL WASTE TRACKING FORM NUMBER <br />! w® 0016 sterl te• IN CASE OF EMERGENCY CONTACT: CHEMTREC 140424-M STANDARD MANIFEST 001-10- STO <br />. RhL 4inrrh,a M. 301 - 7 CUSTOMER NO. 21132 MDFRQOBWPG <br />1. Generator's Name, Address and Telephone Number I <br />A9TN : I <br />GOLDEN LIVING BYPANA - 569 <br />4545 SHELLET COURT <br />STOCMv, CA 95207 <br />9 477-0271 1/25/2010 <br />CUSTOMER NUMBER GErEmmFrs REG0mTQra 1 <br />2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE <br />2C. NO. OF 20. VOLUME <br />UN3291, Regulated Medical Waste, n.os.. <br />CONTAINERS <br />6.2. IGU TEI57 90 Gal Tub Bio 12 Cu tt <br />Cu Ft. <br />U11329t, Regulated Medical Waste, n.o.s.. <br />6.2, PGII TE49 - 37 Gal Tub (Bio) (4.9 cu ft) <br />CU Ft. <br />UN3291. <br />3291. Regulated Medical Waste, n.o.s., <br />5 <br />® <br />1814 - 44 tial Tub(Bio) (5.9 cu ft) <br />• CU Ft. <br />6.23291, Regulated Medical Waste, n.o.s., T821 - 20 tial Tub(Dio) (2.7 cu ft) <br />6.2, PGiI <br />Cu Ft. <br />W <br />UN3291, Regulated Medical Waste, n.o.s.. <br />Z <br />6.2, PGII T818 - 20 Gal Tub (Path) (2.7 cu tt) <br />Cu Ft. <br />W <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2. PGI. 1 - 20 Gal Tub(Cheng) 2.7 CU tt <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s.. <br />6.2, PGII <br />Cu FL <br />UN3291. Regulated Medical Waste, n.o.s.. <br />6.2, PGII <br />Cu Ft, <br />alto <br />Cua Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consigniment are fully and accurately T®TALJ �' t .5 Cu Ft. <br />described above by the proper shipping name, and are ciassifi4 packaged. marked and labelled/placarded, and <br />are in all respects in proper condition for transport according to applicable <br />�l international and national governmentregutatiau.` <br />4&5/12� <br />Print ed Name Sfgnatuse Data <br />4. TRANSPORTER I ADDRESS: Phone e: (569)275-1121 <br />W <br />SteriCycle, Inc. 'This is Thcou h Shipmen `�licabis Permit Numbers: <br />90 <br />4135 Nest Swift Ave. Ratuler Reg# 3400 <br />a <br />Freano,Ca 93722 <br />E <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Ttn V; <br />Print/Type Name Signahxe Data <br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N: <br />Applicable Permit Numbers: <br />$ <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />S. INTERMEDIATE HANDLER 31TRANSPORTER 3 ADDRESS: Phone Y; <br />o <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Printlrype Name Signature Date <br />7. DISCREPANCY INDICATION <br />ai A to = Noth Sal* Lake, UT <br />y <br />8A. Designated FOItty: 88. Alternate Fedlity aiC. Alternate Facility: ®8D, Alternate Facility: <br />"M <br />f ytcle Inc it- tncfrie Inc Inc-Autodailm <br />Q <br />4135 W. SWIFTAVE SON 1100 1345 DIM SO C 1775 E 25TH SIREET <br />" <br />Q CA NORTH SALT LAKE CVTY, � CA S45T7VERNON. CA SOW <br />(801) -tm (51O}562-2117 t�")362-300 <br />W <br />P'i�G t �1 i t1 i�TWOSTM -36 'i�s31 S't'26 -26 <br />DALE <br />¢ <br />I- <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept Untreated medical Wastes and that I have <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />2 5 2012 <br />Printti NamsJAN Signature Date <br />