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-� -�- MEDICAL WASTE TRACKING FORM NUMBER
<br />`® Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-600424-9300 STANDARD MANIFEST �t t0{ig S3D
<br />° °d CUSTOMER NO. 21132 ' Route �- 301 - 7 M412FR170t:_2JD
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GOLDEN LIVING SYPANA -- 569
<br />4545 SHELLEY COVITT
<br />STOCK'l N, CA 95207
<br />UN3291. Regulated Medical Waste,
<br />62, PGII
<br />UN3291, Regulated Medial Waste,
<br />28.
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<br />GENERArowB ftaa im Y
<br />CONTAINER TYPE
<br />TB49 — 37 Gal Tub (Bio) (4.9 Cu ft)
<br />TU14 - 44 G41 Tub(Rio) (5.9 M. ft)
<br />TB21 - 20 Gal Tub(Bio) (2.7 cu ft)
<br />TB15 - 20 Gal Tub gPath) (2.7 cu ft)
<br />7Y35 - 20 Gal Tub (Chem*) 12.7 cu ft)
<br />—0271 3/7/201;
<br />2C. NO. OF 20. VOLUME
<br />CONTAINERS
<br />2 i 11 . 6 Cu
<br />3. Generator's Certification: 9 hereby dedare that the contents of this consignment are fully and accurately I T®TALS 111- I 1 f * Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarcled, and
<br />are In all respects In proper condition for transport according to applicable international and national governmental regulations"
<br />Printecirryped Name rid �" Signature Date ` ®�
<br />4. TRANSPORTER 1 ADDRESS: Plane e:
<br />CC (559)275-1121
<br />', i- Steri�cyale, Inc. ❑ ',:Itis is r gh ShfpmeatMp�IePermit Numt,ers:
<br />50 4135 West Swift. Ave. Hauler Reg# 3400
<br />2N Freano,Ca 93722
<br />a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />F- Print/type Name ®V Signature Data 3
<br />— /it.
<br />2A. DESCRIPTION OF WASTE
<br />N
<br />UN3291, Regulated Medical Waste,
<br />W
<br />6.2, PGII
<br />UN3291Regulated Medical Waste,
<br />F,
<br />6.2, PGli
<br />%is
<br />Medica! Waste,
<br />6 SII
<br />®
<br />Regulated
<br />23
<br />Q
<br />UN3291, Regulated Medleal waste,
<br />It
<br />6.2, PGII
<br />W
<br />UN3291, Regulated Medial waste,
<br />6.2. PG11
<br />W
<br />ar
<br />UN3291, Regulated Medial waste,
<br />r:7 DP_II
<br />UN3291. Regulated Medical Waste,
<br />62, PGII
<br />UN3291, Regulated Medial Waste,
<br />28.
<br />aimiom�uuuis�ainimuimuui
<br />GENERArowB ftaa im Y
<br />CONTAINER TYPE
<br />TB49 — 37 Gal Tub (Bio) (4.9 Cu ft)
<br />TU14 - 44 G41 Tub(Rio) (5.9 M. ft)
<br />TB21 - 20 Gal Tub(Bio) (2.7 cu ft)
<br />TB15 - 20 Gal Tub gPath) (2.7 cu ft)
<br />7Y35 - 20 Gal Tub (Chem*) 12.7 cu ft)
<br />—0271 3/7/201;
<br />2C. NO. OF 20. VOLUME
<br />CONTAINERS
<br />2 i 11 . 6 Cu
<br />3. Generator's Certification: 9 hereby dedare that the contents of this consignment are fully and accurately I T®TALS 111- I 1 f * Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarcled, and
<br />are In all respects In proper condition for transport according to applicable international and national governmental regulations"
<br />Printecirryped Name rid �" Signature Date ` ®�
<br />4. TRANSPORTER 1 ADDRESS: Plane e:
<br />CC (559)275-1121
<br />', i- Steri�cyale, Inc. ❑ ',:Itis is r gh ShfpmeatMp�IePermit Numt,ers:
<br />50 4135 West Swift. Ave. Hauler Reg# 3400
<br />2N Freano,Ca 93722
<br />a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />F- Print/type Name ®V Signature Data 3
<br />— /it.
<br />S. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone It:
<br />N
<br />Applicable Permit Numbers:
<br />W
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />F,
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone f
<br />%is
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printfrype Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />Trwisferred cordainers, to A to : North Saft Lake, HJT
<br />8A4 Designated Factiity: C3 8a. Attemate Feci tty: 0 SC. Alternate FactIlty: fl0. fadw.
<br />S erlt:yde Inc -ALtodave a Inc- IricineralkIn SterkWe Inc -Autodm Stericyde Inc -Autodm
<br />4135 W, SWIFT AVE 80 NORTH t 101) WEST 1345 DOOM DrWe Ste C 2775 E 20H STREET
<br />H
<br />y
<br />FRESNO,CA 93722 NORTH SALT LAKE CITY. U Sart CA 94577 VERNON, CA 90423
<br />(559) 275 - 1121 (801) six - 1555 (5 10) 562 - 2177 (323) 362 - 3000
<br />I S1 T22 3A -448-.W-36 TS311T'SIOST25 TSIOST 26
<br />a
<br />W
<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 />H
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />DALE OM
<br />Pri Name I .4# Signature Date
<br />12
<br />ORIGINAL
<br />
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