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-------- -- — MEDICAL WASTE TRACKING FORM NUMBER <br /> O®� Steric ale' 0 f u `NCY C21NTACT:CHEMTREC 1-800-424- STANDARD MANIFEST 001-10.00-STD <br /> !' PtatatllnpPeo,6.tedutlnppitY CUSTOMER NO.21 1*tDFR00G2LH <br /> 1.Generator's Name Address and Telephone Number <br /> LA SALETTE CONVALESCENT <br /> 537 EAST FULTON STREET <br /> STOCKTON, CA 915204 <br /> (209) 465-2066 2/6/2015 <br /> CUSTOMER NUMBER 6081745-018 GENERATOR'S REGISTRATION# <br /> 2A.DESCRIPTION OF WASTE 29. CONTAiNERTYPE 2C. NO.OF 2D. VOLUME <br /> UN3291rRagulatod Medical Waste,n.os, <br /> TBOS – 40 Gal Tub (13a.o) ( .3 cu ft) CONTAINERS <br /> 6.2,PGiI Cu Ft. <br /> UN3291 Regulated Medical Waste,n.o.s., asx Tub (UV+) (4.9 Cu tt) <br /> 6.2.PGII Cu Ft. <br /> p. UN3291 Regulated Medical Waste,n.o.s., A G) (3a Cut t) <br /> O 6.2,PGII Cu Ft. <br /> Q UN3291 Regulated Medical Waste,n.o.s., <br /> 6.2,PGI Cu Ft. <br /> LLL! UN3291 Regulated Medical Waste,n o.s., a tjZ – eM* Cal TUU`4.14CEWT <br /> tZ 6.2,PGII Cu Ft. <br /> UN329t Regulated Medical Waste,n.o.s., WB 3--(sa.07 Ew43–(Fath)I 43–(Chemo) Gal Tub(5.7CUFT) <br /> 6.2,PGII Cu Ft <br /> UN3291,Regulated Medical Waste,n o s, MW_ – Rosyystems Cardboard Box (4.2 teat ft) <br /> 6,2,PGIE Cu Ft <br /> 6UN3229C�11�Regulated Medical Waste,n.o.s., l� <br /> s Cu Ft <br /> li Cu Ft <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS ® Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and labeited/pfacarded,and <br /> are In all respects In proper condition for transport according to applicable International and national govemme regulations." � <br /> PrintedlTyped Name Signature Date .,. <br /> 4.TRANSPORTER'SEWIFf�I.es Inc. T '5 is a Thry h shipment Phone#' 4} <br /> 4135 W. Swift Ave Applicable Permit Numbers: <br /> 'F reaao,CA 93722 I3aulec Reg# 3100 <br /> in <br /> a a TRANSPORTER C TIFICATI N:R of mecitcal waste as described a e. <br /> PrInVType Name Signature Date <br /> S.INTERMEDIATE HAN LER 2/TRANSPORTER 2 ADD S: Phone 4: <br /> a Applicable Permit Numbers <br /> a� <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> " PrinVType Name Signature Date <br /> M <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone# <br /> a Applicable Permit Numbers: <br /> U <br /> M INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> zx <br /> PrinVTyps Name Signature Date <br /> 7.DISCREPANCY INDICATION Transferred COIF , CU ft to- North Sal Lakes UT <br /> W <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> received the above Indicated r I a bpi tth`tEE11e r�`uirement outlined in that authorization. <br /> rint%pe fdmo ;Igneture Date <br /> ORIGINAL <br />