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MEDICAL WASTE TRACKING FORM NUMBE, 000 Stericycte' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.4249300 STANfMRD AAAraFESTtIdi-70-O&SIE} 000 CUSTOMER NO. 21132 1. Generator's Name, Address and Telephone Number A Il l f II1 Hill I GOLDEN LIVITI•G BYPAIA - 569 4545 SHELLEY COURT STMWMN, CA 95207 (2021 477-0271 2 29 201 UN3291, Regulated Medical Waste, n.o.s. 6.2. FGII UN3291, Regulated Medial Waste, n.o.s. 6.2, PGII 20. Gerttt=.nnroas R>:cas m'noN It LINER TYPE TO49 - 37 Gal Tub (BW (4.9 cu ft) T814 - 44 Gal TU21 MO) (5.9 cls ft) T021 - 20 Gal Tub(lii (2.7 cu ft) TB15 - 20 Gal Tub (Path) (2.7 cu ft) 3. Generator's Certification: "1 hereby declare that the contents of this consignment are fully and accurately TOTALS 11110 - described by the lumper shipping name. and are classified, packaged, marked and labetled/placarded, are in all respects in proper on for transport according tc applicatye international and national govern ntal regulations.° a ® re i ^J 2 /L A I 4. TRANSPORTER t ADORESS: - F " y il t° Stericycle, Inc. ❑ This is ou h rc 4135 Rest Swift Ave. to Frezno,Ca 93722 0.7- TRANSPORTER C mewaswre. Cr CERTIFICATION: Receipt of medical waste as described ab Print/Type Name e/ ' �" signature S. INTERMEDIATE HANDLER 2 f TRANSPORTER 2 ADDRESS: er INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature 2C. NO. OF 2D. VOLUME CONTAINERS Cu (� Cu ' • Cu Cu pf ( Data • Phone x (559) 275-1 21 pipplicable Permit Numbers: Hauler Reg# 3400 Phone #: R Applicable Permit Numbers_ Date G. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone If: W I § Applicable Permit Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of Medical waste as described above. Printrtype Name Signature Date T. OIS_CREPANCY INDICATION Designated St"ICycift Inc �.► 4135 W. SW FT AVE: K y # ti ;r :fl `iCi. ►, jir. ► I1 17 M11 ht 8C. Altern®ts Facility: Sterkyde 1345 IncDAY! ft C Sari Leandro, CA W7 (510) 562 - 2177 TS31 725 VERNON,2775 E 20M STREET SM23 1323) i;Tr MM t TS/OST-26 TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have receivedittlB_. ,,,4 ` ted wastes in accordance with the requirement outlined in that authorization. VER? Print/Type - -_- Signature Date ORIGINAL CUSTOMER NUMM 2A. DESCRIPTION OF WASTE UN3291, Regulated Medical Waste, I 6.2. PGII UN3291. Regulated Medial Waste, 6.2, PGII 6"Ill Regulated Medial Waste, ® UN3291, Regulated Medial Waste, Q 6.2. PGII UN3291, Regulated Medical Waste, 6.2, PGII W 2 a N329il Regulated Medial waste, UN3291, Regulated Medical Waste, n.o.s. 6.2. FGII UN3291, Regulated Medial Waste, n.o.s. 6.2, PGII 20. Gerttt=.nnroas R>:cas m'noN It LINER TYPE TO49 - 37 Gal Tub (BW (4.9 cu ft) T814 - 44 Gal TU21 MO) (5.9 cls ft) T021 - 20 Gal Tub(lii (2.7 cu ft) TB15 - 20 Gal Tub (Path) (2.7 cu ft) 3. Generator's Certification: "1 hereby declare that the contents of this consignment are fully and accurately TOTALS 11110 - described by the lumper shipping name. and are classified, packaged, marked and labetled/placarded, are in all respects in proper on for transport according tc applicatye international and national govern ntal regulations.° a ® re i ^J 2 /L A I 4. TRANSPORTER t ADORESS: - F " y il t° Stericycle, Inc. ❑ This is ou h rc 4135 Rest Swift Ave. to Frezno,Ca 93722 0.7- TRANSPORTER C mewaswre. Cr CERTIFICATION: Receipt of medical waste as described ab Print/Type Name e/ ' �" signature S. INTERMEDIATE HANDLER 2 f TRANSPORTER 2 ADDRESS: er INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature 2C. NO. OF 2D. VOLUME CONTAINERS Cu (� Cu ' • Cu Cu pf ( Data • Phone x (559) 275-1 21 pipplicable Permit Numbers: Hauler Reg# 3400 Phone #: R Applicable Permit Numbers_ Date G. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone If: W I § Applicable Permit Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of Medical waste as described above. Printrtype Name Signature Date T. OIS_CREPANCY INDICATION Designated St"ICycift Inc �.► 4135 W. SW FT AVE: K y # ti ;r :fl `iCi. ►, jir. ► I1 17 M11 ht 8C. Altern®ts Facility: Sterkyde 1345 IncDAY! ft C Sari Leandro, CA W7 (510) 562 - 2177 TS31 725 VERNON,2775 E 20M STREET SM23 1323) i;Tr MM t TS/OST-26 TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have receivedittlB_. ,,,4 ` ted wastes in accordance with the requirement outlined in that authorization. VER? Print/Type - -_- Signature Date ORIGINAL