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so* �*C. I MEDICAL WASTE TRACKING FORM NUMBER
<br /> .:d fV�'�CyCle` IN CASE OF EMERGENCY CONTACT:CHEMTREC 1.800-424.0300 STANDARD MANIFEST 001-10.08•STO
<br /> Route #: 122 4 CUSTOMER NO.21132 MICI ROOT; B
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ATT11:Liz Peixeixa III Ill I I II 11111111111111111111 Hill 111111111
<br /> 1A Is?== C0110=13CENT
<br /> 537 BAST T'ULTb'N 5 T
<br /> STOC N, CR 95204
<br /> (209) 466-2056 6/4/2010
<br /> cuSToMunNunman 6091745-018 GENERAMTSREQISTRATIONff
<br /> 2A.DESCRIPTION OF WASTE 213, CONTAINERTYPE 20.NO.OF 2D. VOLUME
<br /> CONTAINERS
<br /> i UN32g1 Regulated M4dtml Waste,n o.s, gp4 28 ,pal Tub (Rio) (3.7 ca Et)
<br /> 8,2,PGI) Cu Ft
<br /> 6N32Gil Regulated M4dleal Waste,0.04,T BX 37 Gal Tub (Rio) (4.9 on ft) Cu FI.
<br /> CC® 823PGI� Regulated M4dfcal Waste,n,o,s, a 4 44 Gail Tub(Rio) (5.9 CIA tt) .� Cu Ft,
<br /> ,� UN32g� Rogulatad M4dloal Wtiele,it.o.s„ B .t w f S TE15-f ) ���f__._ ,?20 Coal Tub(2.7oUVT)
<br /> 6,2,PG Ou Ft.
<br /> tU UN3291 Regulated M4dfcal asto,n.o.s,,
<br /> W 0.2,PGII Cu Ft.
<br /> �r UN3291 Regulated M4di4al Waste,q.os., Cu Ft,
<br /> 6,2.poll 43r(„____)/WE43-t )/WC43—( ) Gal Tub(s.7auP'T)
<br /> 623PGI�Regulated M4dlcait'Jaste,n.o.s„ Erlosystems cardboard 13ox (4.3 cu 'Et) Cu Ft,
<br /> U291 Regulated M4dfcal Waste,n.o.s„
<br /> T6PGI Cu Ft.
<br /> UN3281 Rogulated M4dfcal Waste, Cu Ft
<br /> 6.2,PGI
<br /> S.Gq Orator's Cortif[cation,ul hereby declare that the contents of thfs consignment are fully and rately TOTALS ® i Cu Ft
<br /> rl d above b the proper ehlpping name,and are classified,packaged,marked and labelle place ded,and
<br /> are in a respects In proper condition for transport according to applicable(nternattonal and national go rnmental regulations"
<br /> N11
<br /> 1
<br /> i P me pod Name
<br /> 4.TR SPORTER t ADDRESS: PhOn(at�t66j 7 �79 2
<br /> St:ericycler Inc. Th±s is a Throug tiiri Applicable Permit Numbers:
<br /> .,c 4'.36 W. Swift Ave Hauler Regis 34010
<br /> I N rremnotch 93722
<br /> a TRANSPORTEIa RTiFI .AT ReeOlpt of decal waste as describe5abo
<br /> PrInUTypo Name Signature pate
<br /> ~�
<br /> 5.INTERMEDIATE HANDLER 2/7RANSPORTER 2 DDRESS: Phone 4:
<br /> 1 Applicable Permit Numbers:
<br /> ` INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpt of medical waste as desodbod above.
<br /> PrinMpe Name Signature Date
<br /> 0.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone Ii:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpt of medical waste as described above,
<br /> �— Prinf/1ypoNamo Signature Dale
<br /> 7,DISCREPANCY INDICATION
<br /> oat hated Foollity. 00,Alternate Facility; 8c.Aitemato Facility: 8D.Altomalo Facility;
<br /> Med.cycle,Inc. ledaycle,Inc. Stericycle.Inc, Cmrb Marfon,lnc
<br /> 5 4136 W.SMAVO 0 N,Foxboro tJlt m 1661 Shabn Orl" 4960 Brooldrke Rodd NE
<br /> W4 � Frefa a 93722 orth Salt Lake,UT 64064 Hollister,CA SM23 Brooks,OR 97306
<br /> (866 7t 3- 422 EOE' 80f 936-f 1T9 (080)783.7422 IS05 3.0090
<br /> TSIOST-22 OA4�f� WtlAr38 TWOST63 Peet 03641
<br /> TREATMENT FA tkAX)LI:I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the above Indicated Waste$to accordance yvith the requirement outlined in that authorization,
<br /> Print/rype Name Signature Data
<br /> Cqq Pt ribr 6, ou 11 to
<br /> N
<br /> _. ORIGINAL
<br />
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