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*.%'.'o S k'CICyCle' poefigojpjjyjtCY CrACT: CH9MTRF:C 1.800.424.0300 <br />a NOW' V N ff It. A-*4+r1bk: CUSTOMER NO. 21132 <br />MEDICAL WAST&TRACKING FORM NUMBER <br />srnMDFROBH86Vo-0e sra <br />ORIEUNIAL. <br />1: Generator's NameandTe7tephone Number <br />irlAtnddreFr <br />A8 J8tla;4%�nk l/t.lai•e, <br />l l <br />BT.MMVEN CARE CENTER <br />6940 PACIrIC AVE <br />STO=ON, CA 95207– 2602 <br />(209) 477-4817 <br />12/7/2015 <br />-f <br />CuoromanNumliEq (5080854--001 GENERATOW8REOISTRATtoNO <br />2A, DESCRIPTION OF WASTE <br />23. CONTAINERTYPL <br />2C. NO. OF <br />CONTAINERS <br />20. YOLUMS <br />U113291 ReautatedMed!caiWaste, n.os., <br />6,2 PGIi <br />TB05 ^ 40 Gal Tub (Bio) (5.3 Oil ft) <br />Cu Ft. <br />823229911�RegufaledfledtcalWiste,n,o.s., <br />TQ -9 — 37 tial Tub (i3 0) (4.9 Ott rt) <br />Cu Ft. <br />UN3291 Reglated Medical Vasia, n.o.s., <br />0.21 Poll <br />a Q <br />f . Cu Ft. <br />p <br />UN329t Regulated Medical Waste, p,0,8., <br />8.2, PGII <br />_ <br />CU Ft <br />UJ <br />UN32011 Regulated Medical Waste,n.os., <br />0.2, PGII <br />o — a G stab a T <br />Cu Ft. <br />�7 <br />UN23PGI� RogubladMedical Waste, n.o.s., <br />Wb43, (I;d a} BW03— (Pai:h) oWC2^ (t7ht ma} clai. Tub (5.7GuFT) <br />Gu Ft <br />U091 RegubledMdtcaltYasle.n.o,s„ <br />0.2, nil <br />IiRI3 Siosystems Cardboat:d Box (A.2 au ft) <br />QQ Ft. <br />UN3 91polRegulated Medical Waste, n o s., <br />Cu Fl, <br />Cu Ft <br />3, Generator's Certification: "I hereby declare that the contents of this consiglurlent are fully and accurate TOTALS -110. <br />Cv Ft. <br />described above by the proper shipping name, and are classified, pacRaged, marked and labelled/placard ,In <br />International and national ver ons" <br />rospecls in proper condition f r transport according to applicable <br />Pnn a ed Name 9nafur <br />TRA ORTSRf fflffiyole, Inc. Q This 3s ough Shipment <br />etD� <br />Phone# <br />6 <br />fir <br />& <br />4.35 V. Swift; Atte <br />Appiicabte Permlt Numbers: <br />IInulex 12egfl 3800 <br />rranno,CA 93722 <br />TRANSPORTER CERTIFICATION' R I ofmedical vraste as described a f <br />PrfnMpe Nom s Signature <br />Date <br />U. INTERMEDIATE HANDL R 2 /T ANSPORTER 2ADDRESS: <br />Phone 4, <br />Applicable Permit Numbers: <br />c <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinVrypo Name I Signature <br />Data <br />i <br />U. INTERf4EDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone 0: <br />Applicable Permit Numbers, <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />Print%ps Name Signature <br />Date <br />7. DISCREPANCY INDICATION Transfarred _.--.-..-- containers, CI1 It to : Not1i1Soft Like, UT <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />TREAT EAT FACILITY: I certify that 1 have be n authorized by the appiIcable state agencyy to accept untreated medical <br />wastes and !fiat I have <br />receive the abov/j0-d-writ0stins accords ce with the requirement outUned in that authorizatfbn. <br />d <br />PrinMp: Na Signature Date <br />ORIEUNIAL. <br />