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*_;i0_1 <br />CAL WASTE TRACKING FORM NUMBER <br />Stericycle' IN CASE OF EMERGENCY CONTACT: CHEUTREC 1 }•424-93W STANDARD MANIFEST 001.104*SM <br />oP..w•- I "aa CUSTOMER NO 21132 <br />n,...r„ A. 'ant .. ? 61T1FR[if2C"[1K4 <br />1. Generator's Name, Address and Telephone Number <br />ATTN: SII 1111111111111111 oil <br />GOLDEN LIVIitG HYPARA - .569 <br />4545 SBSL EY° COURT <br />STOGR7001 CA 95207 <br />(2021,477-0271 2/22/2012 <br />Cwroiu rr NUAMEA 4nQA8 GateRAUM REOM Mnom 0 <br />56-001 <br />2A. DESCRIPTION OF WASTE 29. CONTAINER TYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3291, Regulated Medial Waste, nos.. <br />CONTAINERS <br />112, PGII TS57 - 90 Gal Tub Bio 12 cu it) <br />Cu Ft <br />UN3291, Regulated Medical Waste, mos, <br />6.2, PGII T849 - 37 Gal Tub (bio) (4.9 cu it) <br />Cu Ft <br />Regulated Medical Waste, n.0-&' <br />6.2 <br />C a <br />® <br />PGII T914 - 44 Gal Tub (Bio) (5.9 cu it) <br />J + J Cu Ft <br />6.2. PGII Regulated Medical Waste, nos., T921 - 20 Gal Tub (Bio) (2.7 cu it) <br />Cu Ft. <br />W <br />UN3291, Regntated Medical Waste, mos.. <br />6.2. PGIITB15 - 20 Gal Tub (Path) (2.7 cu tt) <br />Cu Ft. <br />W <br />u. <br />UN3291, Regulated Medical Waste, mo -S., <br />6.2. PGII 7Y15 - 20 Gal Tub (Chemo) (2.7 Cts Et) <br />Cu Ft. <br />UN3291, Regulated Medical Waste. n.o.s., <br />6.2, PG11 <br />Cu Ft. <br />UN3291. Regulated Medical Waste, n.os., <br />6.2. PGII <br />Cu Ft, <br />11-06 <br />Co F. <br />8 <br />3. Generator's Carittleatdon: -1 hereby declare that the Contents of this consignment are fully and accurately TOTALS ® , + -t Cu Ft. <br />described above by the proper shipping name, and are classified, packaged. marked and labelledtplacarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations" <br />r <br />h <br />PrinlW ped Name !�--Jta Signature Date <br />Ix <br />4. TRANSPORTER 1 ADDRESS: Phone A: <br />(559)275-1121 <br />W <br />Stericycle, Inc_ ® This is to qh 5hfpmen8ppl' Permit <br />40 <br />4135 lest Swift Ave. Hauler Reg# 3400 <br />a W <br />Fre3no,Cai 93722 <br />a Q <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. ,..• <br />a <br />!/ <br />�� e. y avr_OL �i2 �Z <br />PrintlType Name • Signature Date <br />S. INTERMEDIATE HANDLER 2 1TRANSPORTER 2 ADDRESS: Phone a: <br />Applicable Permit Numbers - <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinUtype Name Signature Date <br />6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone It: <br />o <br />App9oab4e Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinUType Name Signature Date <br />7. DISCREPANCY INDICATION <br />Transhimd mesh iers, cul 1} to : North Saft lake, UT <br />} <br />t=- <br />if <br />SA Designated Facility: a8. Alternate Faci ty: SC. Alternate Faeftlty: E0, Alternate Fac[tity: <br />SWricoe Inc -AutDdave a Imo• Incineration Startcycle Inc-Auto=dm Siertcycle Inc <br />a <br />a Drive Ste C 28 E 2M STREET <br />4135 W. SWIFT AVE W N 1100V,IE T 1345 77 <br />v' <br />FRESNO.CA Wn ANNE MU NORTH SALT LAKE CITY. San CA 90577 VERNON. CA 30023 <br />Z <br />1559) 275 - f 12 f ED t8ol) - 1555 (510)60- 2177 1323) 362 - 3000 <br />TS 2 3A448-0-36rs311 s ZSIOST 26 <br />FEB 2 2 ' 012 <br />TREATMENT FACILITY: i certify that I have been authorized by the applicable stale agency to accept untreated medical wastes and that I have <br />received the above indicated,AAfastes ccordance With the requirement Outlined in that authorization. <br />Print(T Name lure Dale <br />