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. — —_ - __* <br />MEDICAL WASTE TRACKING FORM NUMBER <br />COO• <br />Stericyde` IN CASE OF EMERGENCY CONTACT: CHEMTREC 148 —D ®0424 STANDARD MANIFEST 001-10-MSTD <br />•. Mw •I w: Route A: 301 - 4 CUSTOMER NO. 21132 MDFROOC3HD <br />12 2 ORIGINAL <br />1. Generator's Name, Address and Telephone Number <br />A'i"PN <br />W=11 LIVING HTPAXA - 569 <br />4545 SBELL19Y COURT <br />sToCKTON, CA 95207 <br />(209) 477-0271 3/14/2012 <br />CustoumNumsER 6080856-001 Gere:tuTwsRsaern ymS <br />2A. DESCRIPTION OF WASTE 29. CONTAINERTYPE <br />2C. NO OF <br />20. VOLUME <br />UN3291, Regulated Medical Waste. n.o.s., TB57 — 90 Gal Tub (Bio) (12 cu ft) <br />CONTAINERS <br />6.2, PGII <br />Cu FL <br />UN3291, Regulated Medical Waste, n.o.s., T549 — 37 Gal tub (Bio) (4.9 cu it) <br />6.2. PGI2 <br />Cu FL <br />Regulated Medical Waste, aos., TB14 — 44 Gal Tub (Bio) (5.9 Cu tt) <br />®UNMI. <br />6 <br />or Cu Ft. <br />Q <br />3291!. Regulate[ Medical Waste, n.o.s., o cu <br />CC <br />6.2 <br />Cu Ft. <br />W <br />UN3291Regulated Medi Waste, n.cs., TiUS — 20 Gal Tub (Path) (2.7 cu ft) <br />Z <br />6.2, PGli <br />Cu Ft. <br />W <br />UN3291. Regulated Melimi Waste, n.o.s„ �r1t]5 — 20 8a1 Tub (C71e�o} (2.7 cu ft) <br />6.2. PGI. <br />Cu Ft. <br />UN3291. Regulated Medd Waste, n.os., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medial Waste, n.o.s.. <br />6.2, PGII <br />Cu Ft, <br />Pharmaceutical Wastp <br />Cu FL <br />j <br />3. rator's Certification: "t hereby declare that the contents of this consignment are fully and accurately TOTALS Po � ®' ` Cu FL <br />described above by the proper shipping name, and are classified, packaged, marked and labelplacarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations" <br />Print ed Name CAV%- i`� t` • �' i0) u C "a" Si natureDate <br />Q <br />4. TRANSPORTER t ADDRESS: Pune #: <br />Stericycle, Inc. D This is a It Shipment Applicable Permit Numbers: <br />4135 ffe3t Swift Ave. Battler Reg# 3400 <br />ca <br />E'Ceano,Ca 93722 <br />N <br />oa <br />TRANSPORTER CERTIFICATION: Receipt of medial waste as described above. <br />~ <br />A <br />Y <br />PnrafType Name • Signature Date <br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #: <br />cc <br />Applicable Permit Numbers: <br />1h <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt described <br />of medical waste as above. <br />PrintfType Name Signature Date <br />�, lad <br />8. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone #: <br />W g 9 <br />Applicable Permit Numbers: <br />CERTIFICATION: <br />INTERMEDIATE HANDLER /TRANSPORTER Receipt of medical waste as described above. <br />Printfrype Name Signature Date <br />7. DISCREPANCY INDICATION Transbillred Its, cu A to: NoM Saft Lake, UT <br />y. <br />8A, DesIgIrAted Facility: 88, Attemate Factilty: 8C. ANamsto Facility: 80. Altamate Facility: <br />tStarkyde <br />Inc -A Inc, Incineration Inc -AUbxftn <br />4 y <br />4135 W. SWFT AVE 90 N 1100 1345 Ste C 2775 E 26TH STREET <br />LL <br />O,CA 93722 N SALT LAKE CITY, U Son CA VERNON, CA 90023 <br />( 275 - 1121 (8111) sin - I WS (5 10) 5V - 2177 (323) 362 - 3000 <br />U.1 <br />TS J4-36 T83tR"S -26 <br />4 <br />CcCc al <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 />PrintlT N Al Signature Date <br />12 2 ORIGINAL <br />