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•Date:081=012 Time:07:21 PM To: 2094636910 From:Patrice Rogers Page 3/3 <br /> 00 <br /> 0*• Stterkycle' IN CASE OF EMERGENCY ACT:CMEMTREC 1.OW424-OW sf o a�,r-�� <br /> j ®® " +"�.4- I'* Route 6: 100 - NO.21132 HDFR J'1"� <br /> 1.Generator's Name,Address and Telephone Number <br /> AWN <br /> GOLDIElt LIVING GE IDE <br /> 2740 H CALIFORNIA ST. <br /> STOCKTON, CA 95204 <br /> (209) 466-3522 10/25f2011 <br /> I <br /> tlrstmnrttlwat 6080848-001 GENERATOOM RIWIMATMy <br /> 2D. Wta1ME <br /> Ulum <br /> - 90 Gal Tub MW (1.2 Cu tt) <br /> Cu Ft <br /> 9 - 3T Cal (Diol {4.4 Cut 'tt) <br /> Cu Ft <br /> tTC 44 %,"(W (3.9 ou tis) <br /> Jbipw Cu FL <br /> 5I D Cu Ft <br /> - 20 3. Tub (Patch) 42.7 cu tt) <br /> Cu Ft <br /> 62Tr15 - 20 Galt Tub (Chemo) (2.11 Cu tt) <br /> Cu Ft <br /> G <br /> Ft <br /> Remom maw waft aAc <br /> Cu Ft <br /> rhamaceutkcal NAM <br /> 99 EL <br /> 3 CertHdcattom"I hereby declare that the contents of this oonsignrnent are"and accurately r Cu FL <br /> described abo-by the proper shipping name,and are classified.packaged.marked and tabelledtpleaarded,and <br /> are in an respects in proper cordon for transport according to applicable Internobell and national Wommental regulations" <br /> Printed/ryped Namenatu Date WAMO� <br /> 4.TRANSPORTER 1 ADDRESS: Phone N: <br /> Stericycle, Tnc. ❑ This is a ea gh Shipment <br /> 4135 1• t Ave. Applicable PermitNumbers <br /> Hauler Regi) 3400 <br /> Fresno,Ca 93722 <br /> TRANSPORTER CERTIFICATION:Receipt ot medical waste as above. <br /> F <br /> Name Sg= Date <br /> 5.INTERMEDIA 2/TRtANSPORTER 2 ADDRESS. Phone C <br /> a <br /> AppNrable Permit Numbers: <br /> f <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as scribed above. <br /> Print/Type Name Signature Date <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS- Phone A: <br /> Applicable Permit Nuntors: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrkWType Name Signature Date i <br /> 7.DISCREPANCY INDICATION _ <br /> Trmfemd eu h to- North Sale Lake,UT <br /> Desigpoted FmMMyr: a8 Afternsts Facility: El aC.AMw=W FeeilWy AD,AftwwtaFacility. <br /> Stgdayde Inc-ALAodave Ino-Irlicharalim Sterkyde Inc-AU10dave Stericide Inc- <br /> AutDctm <br /> t3 4135 W.SWIFT AVE 90 NORTH 1100VYEST 1345 DaoNtle Drive Sia C r 2775 E 2STN STREET <br /> FFtESNO,CA 93722 NORTH SALT LAKE CITY,U7 San Leandro.CA 94377 VERNON,CA 2=3 <br /> ! (554)273- 1121 (801)235-1555 (510}562-2177 (323)362-3000 <br /> i Lu '1TSIOST22 3A-446-.IA-36 TS31ff' OSl'25 TSIOST726 <br /> t TREATMENT FACILITY:I certity that i have been authorized by the applicable state agency to accept untreated medical wastes grid that I have <br /> received the above indicated wastes In atoordance with the requirement outlined in that authorization. <br /> DALE ANNE OR71Z <br /> Prinow.Name AtMMV-911) Signature Date <br /> OCT 2 5 2011 <br />