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- - MEDICAL WASTE TRACKING FORM NUMBER <br /> O•®@PratclingPcople,Pedu<{ngAuk' <br /> OWFPSTANDARD MANIFEST 001.10.06-STD <br /> Stericycle' EC4 : DFRVGr5CUSTO <br /> MER NO.2113 <br /> 1.Generator's Name,Address and Telephone Number <br /> A`P`PN:Lix Peixeira <br /> LA SALETTE CONVALESCENT <br /> 537 EAST FULTON STREET <br /> STOCKTON, CA 95204 <br /> (209) 466--2066 5/29/21135 <br /> CUSTOMER NUMBER 6081745-018 GENERAToris REcusTRATioN 0 <br /> 2A.DESCRIPTION OF WASTE 2B• CONTAINERTYPE 2C. NO.OF 2D. VOLUME <br /> UN3291,,Regulated Medical Waste,n.o.s., TBQS •- 401 Gal Tub (Bio) (5.3 cu ft) CONTAINERS <br /> 6.2,PGII Cu Ft. <br /> UN3291,Regulated Medical Waste,It o.s., TD49 — A TUBOCu <br /> 62,PGII, Cu Ft <br /> fx UN3291;Regulated Medical Waste,n o.s„ — 10 `9 cur <br /> p 6.2,PGIICu Ft. <br /> QUN3291,Regulated Medical Waste,mo.s., 122:t (elperim)26 Sal Ttib(12.ic <br /> 6.2,PGIi Cu Ft. <br /> LLL1 UN3291,Regulated Medical Waste,It o s, 10 — a s t — V tem* Gat Tub(4.14CUFS1) <br /> W <br /> 6.2,PGII Cu Ft. <br /> UN3291 Regulated Medical Waste,n.o.s., WB43-(Sias) PW43-(Path} 43-(Chemo) Gal Tub(5_7CUF'T) <br /> 6.2,PGII Cu Ft. <br /> UN3291 Regulated Medical Waste,n.o.s, Y.BB — Blasystems Gardbraard Bax (4.2 cu ft> <br /> 6.2,PGR Cu Ft <br /> UN3291,Regulated Medical Waste,n.o.s, <br /> 6 2,PGII 03 Cu Ft <br /> Cu Ft <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TAI.s D Cu Ft <br /> described above by the proper shipping name,and are classified,p kaged,marked and labelled/placarded,and <br /> are in all respects in proper dition for transport according to ap i able internatr I and national goner nt re lat{ons" <br /> IPrintedlTyped Name �" — Signature ==PA1e a <br /> 4.TRANSPORTER i A§RKS2G'1yrr-,le, Ino. This is a Through15 pment Phon��eafl: <br /> 4135 W. Swift Ave APPltlatlfetitRegir;400 <br /> a p rt:ar:rntto,CA 93722 <br /> a <br /> RE¢ TRANSPORT RTIFICATION: Receipt of medical waste as describe bo <br /> a ` <br /> F Pnnl/Type Nam Signature Date <br /> S.INTERMEDWIT HANDLER TITRANSPORTER 2 ADDRESS: Phone S: <br /> az <br /> Applicable Permit Numbers: <br /> Iwo <br /> ca <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> — <br /> Print/Type Name Signature Date <br /> Co6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 9. <br /> a Applicable Permit Numbers: <br /> N s a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> — Print/Type Name Signature Data <br /> 7.DI CREPANCY INDICATION Tra is ntalitEC'3, til ft to: North Salt lake,UT <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> ORIGINAL <br />