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cc <br />O <br />4 <br />OC <br />W <br />0 <br />®®p S'" erlcvcle` IN CASE OF EMERGENCY CONTACT:CHEFATRECI•peg-024-9300 <br />®e� Protettls,}hoprnaelz[raAh1L Route #: 126 - 3 CUSTOMER NO. 21132 <br />MEDICAL WASTETRACKING FORM NUMBER <br />STANDARD MANIFEST 001.10.0e•STO <br />1, Generator's Name, Address and Telephone Number <br />ATTN:'rank Juarez1�t� <br />LSI MffAV4W CARE CENTER <br />j5940 FACrI?IC AVE <br />sTOCKTO1I, CA 95207- 2602 <br />(209) 477--98.7 12J18/2015 <br />CusTotrenNUMaen 60$p 54_001 GENERATOR'SREeISTRAMON# <br />2A. DESCRIPTION OF WASTE 2g. CONTAIHi RTYPE 2C. NO.OF 20. VO! UME <br />111,13291Roodlatod AIMWI Waste, n.o.s., cDNTAINERs <br />6.21 PGII TaOS - 40 Gal Tub (Bio) (5.3 ou ft) Ou Ft <br />111113291 RopulatedAtedlralWeste,n.o.s., <br />8.2, Pull TB49 „ 37 Gal Tub (iiio) (4.9 sat ft) Cu Ft <br />URegulated MedtoatWas <br />t <br />8.22,, pall a, n.o.s., T133.4 - 44 Gal TUb (Bio) ($.9 au TW Cu Ft <br />PGI <br />03?91I Regulated Atedleal Waste, R,o.s., T821- (BIO) /TPi5- (Fath) /TY15- (ahwno) 20 Gal Tub (2.7ourT <br />Cu Ft. <br />UN3291 RegUlaleaMemo] WHO. n.e.s, idB31-(Bio}/GB31�(PatH)/WC31-{Chetno)31 Coal Tub(4.3.4CtIP } <br />82, FORGUM. <br />6.23PQIIRepuiatedMedioatlYa4te,nos, WB43»(Bio)/PW43-(Path)/Ct443-(Chemo) Gal Tub(5.70UFT) Cu Ft <br />UN3291 Regulated Medical Waste, n.o s:, <br />0.2,PGIl I;taB - Biosystems Cardboard Box (4_2 au ft) Cu Ft <br />1.193291 Regulated MedicalVA510,n.oS., <br />8.2, PGII Cu Ft <br />Cu Ft. <br />3. Generator's CorgRoatlon:'i hereby declare that the contents of this consignment are fully and accurately TOTALS )0Cu Ft. <br />desedgNabove the proper sh <br />by ipping name, and are classified, packaged, marked and labelledfplacarded, rid / <br />a(-e—J [I r specie n proper condi n for transport according to applicable International and national governrr nlel regulations; . / <br />JA Pri edrIlA ed Name . .aim <br />4. TRA RTER 1 ADDRESS: <br />Stecicyo1e, Ina. <br />a 4136 W. Swift Ave <br />Fresno, Ch 93722 <br />cn <br />a Q TRANSPORTER CERTIFICATION: R pi ofinedlcalwasto as <br />F' PrIAIM150 Name Signal <br />Phone 6. (866)7$3-742'4 <br />This is a Through Ship ant Applicable Permit Numbers: <br />IRuler: Reg# 3400 <br />., <br />S. INTERMEDIATE HDL /TRANSPORTER 2 ADDRESS: <br />Phoned: <br />w <br />Applicable Permit Numbers' <br />Ell <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medioal waste as described above <br />Printflyps Name Signature <br />Data <br />M <br />S. INTERMEDIATE HANDLER 3/TRANSPORTER 3ADDRESS: <br />Phone 9: <br />Applicable Permit Numbers <br />8 g <br />W PI <br />INTERMEDIATE HANDLER ITRANSPORTER CERTIFICATION: Receipt of medical waste as descrlbad above. <br />PrInUType Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />Transferred containers, ou ft to : North Salt Lake, UT <br />Dostpnotod Facility: M Attamatc Facility: 0 $C. Attornate Facility. <br />aD.Aitarnste Faclely: <br />rfaricyLla, <br />, <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />cc <br />TREAT ENT VACILITY. I certlfy that I have bei n authorized by the applicable state agency to accept untreated medical Wastes and that I have <br />recelved the aboveli d at wast accords ce with the requirement outlined In that authorization. <br />� <br />Pdrimp -pion slgnature <br />Date <br />4 <br />