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To: I Sep. 28, 2 0 1 2 4: 0 3 P M 2012-09-21 18:11:52 CDT
<br />No. 45541,97 P. 30umornerCaro
<br />T MFOICAL WASTE TRACKING FORM NUMBER
<br />®® Stericycle` IN CASE ®F EMERGENCY CONTACT": cfieMTnec i-,aw-e24-S3W 87ANWo 9x:pr:ST oor•toaosTO
<br />AosieMe�•r. eaar Route 0: 100 - 19 cusTOMEaN0.21132 MDFROOBQNR
<br />Received Time—Sep, 28,-2012— 4:14PM^No. 0281 ORIGINAL.
<br />1. Generator's Name, Address and Telephone Number
<br />RTTN
<br />MUeMN CARE CZMER
<br />442 E. HAM ION ST
<br />STOCK M, CA 95204
<br />(209) 466.0456
<br />12/13/201!
<br />CUM10ANUMoM 6090852-001. GWEAATOR-cRtawmr"0
<br />2A. OESCRIP7ION OF WASTH 28- CONTAINERTYPE
<br />HOOF 2D, VOLUMd
<br />UN3291Regulated Medical Waste, rhos-.
<br />8.2, Kii vv37 - 90 Gal rtLb (trio) (12 cu ft)
<br />CONTAINERS
<br />u ft.
<br />6 2, 2911 RepulatM Med)021 Waste, 7 Gall. SU13 (8700' (4.9 CU 1't)
<br />Ft.
<br />CU1,139N
<br />Regulalad tu,edlcat Wast i@X9 -44 trite Tub (ViQll (3.9 CU LL)
<br />6,2, PGII
<br />Cu FI.
<br />Q
<br />11113281.Re4ulalsdmedical Waste. n,os.. TIVI — 20 Gal Tub(a3io) (2,1 cut ft'
<br />�
<br />8.2. PGII
<br />u F!.
<br />W
<br />UN29! RegutatectMedicalWaste, A.®.e„ 78.15 - 20 gal tub (each) (2.7 Cu !t)
<br />W
<br />6.2, Pell
<br />Cu F!.
<br />UN3201, Aeguioted Medical Waste, n.ox.,7Yt5 - 20 6e1 ?d1b IChkmo) (2.'7 cu ft)
<br />6,2, Poll
<br />Cu Ft.
<br />IJN3291 Regulated Medical Wada, n.0.s.,
<br />6.2. Poll
<br />Cu Ft,
<br />W4291 Regulated Medical Waste, n.o.s.,
<br />0.2, PG11
<br />Cu Ft.
<br />Pharmaceutical Waste
<br />3. Generators Cerllflcallon:'I haraby declare thel the contenta of Ihls consignment are fully and Scoiretey T®YACs ®
<br />�, Ctj ft
<br />descrlhed above by the proper shipping namo, and are dasstned, packaged, markod and tabeded/ptararded, and
<br />are In all reepeclo In proper condition for transport aaxoiding to oppiloWs inlernatlonaf and national govornmantal ragulat)on
<br />.1 � -
<br />1
<br />IJV Printod /Typod Nana Signotum
<br />Date
<br />4. TRANSPORTER 1 ADDRESS: d
<br />Stericycle, Inc. ❑ This is 1%cough Bhilpm®nC
<br />P e e: (559) 2751121
<br />a
<br />Applicable Permit Numbers'
<br />4135 Rest Swift Ave.
<br />8&,uiec Refit# 3900
<br />FKmn®,Ca 93722
<br />rn
<br />Z
<br />TRANSPORTERFICATION: Receipt of medical waste as dersertb®d a
<br />�
<br />�r
<br />7-11
<br />PrinViype Neme Signature ---
<br />Beta—
<br />s. INTERMEDIATE HANDLER 2 /TAANSPORTER 2 AODAFESS,
<br />Phone 8;
<br />III N
<br />Applicable Permh Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of me4lcaiwaste as descrioed above,
<br />PrIAVlypo Namo 5fgnaiura
<br />Data
<br />a. INTERMEDIATE HANDLER 3 /TRANSPORTER 0 ADDRESS:
<br />Phono e:
<br />8
<br />Peretti NUmDArS:
<br />�
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION; Receipt of medical waste as described above.Apprinpl0
<br />PrintiPypa Name Slgnaturo
<br />DOW
<br />7, DISCREPANCY INDICATION
<br />Trffdfenvd , alt A to : North W Laim, UT
<br />tat
<br />Faoutty:
<br />eG, Aitompdp FaNllty:
<br />Nip-Nnated Canlnty, e0, Altonuno Fpoillry, BC. Aturnoto
<br />A8
<br />Int:-AuwdtlYrr Ino- I Ino -A
<br />-Atbdm
<br />1
<br />135 W, O WFTAVe 30 NOM 1100 MST 1346 DOOM C>I11N1 b'!e C
<br />2770 a WITH STIRWT
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<br />FRESI�IO,CA 93722 NORM SALT LAKE CITY, UT Sun Loandv, CA 94571
<br />VF-. ON. CA 20
<br />(669)276- 1121 Iwo) W- 1559 (610)662-2177
<br />IM 382-3000
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<br />TS109T 2e T931 rel
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<br />TREATMENT FACILITY; i Genifj/ that I have been authorized by the applicable sista agency to aacepl untreated medical wastes and that l have
<br />received the aanbove Indleated wastes In aMordence with tris requlremenl outlined in that authorization.
<br />Pflnt/Type NRMDi . l 3 01 9ignmum
<br />Date
<br />Received Time—Sep, 28,-2012— 4:14PM^No. 0281 ORIGINAL.
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