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To: ISep.28. 2012 4:03PM <br />• ®®O ste►Icycle' <br />®® y ,"o ooftfterA <br />2012-09-21 18:11:52 CDT <br />IN CABS of EMCRDENCY COMM CHEMTREC 1-&* 4244300 <br />ROute is 100 - 18 CUSTOMER No. 21132 <br />No. 4554'97 P. 4c..tamerCare <br />MEDICAL WASTE TRACKING FORM NUMBER <br />WANDAAD MANIFEGT oo/-sboe.8M <br />MDFR008RLV <br />Received Time—Sep, 28,2012— 4;14PM—No. 0281 - IDR1GINAL <br />rpl(4atan itrwe-part t <br />1. Generator's Name, Address and Telephone Number I I I ICI r I� <br />AT": <br />fWVrON CARE CE VM <br />442 E. 70'N ST <br />STOCn-Ot7, CA 95204 <br />(209) 466-0456 12120/2017 <br />COSTOWANtlstaEA 60801352-001 Q04ERAWM'9RECIMUTIOU It <br />2A. DESCRIPTION OF WASTE 20. CONTAMERTYPE <br />20. 00. OP <br />20• VOLUME <br />UN3291 RepulatedMedical Waste, n.o.s., S®SZ gp ®al Tub (Bio) (12 eu it) <br />CONTAINERS <br />0.2, All <br />Cu Fr. <br />UN3291, Regulated Medw Waste, n.o.5, - 77 tial Tub (Bio) (Q. 9 ,u 1t) <br />0.2, PGI► <br />Cos FL <br />Vt <br />UN3 291 Regulated MAdiral wase, n.a. , 44 Gal tub (eioi 15.9 ou it) <br />CU FI <br />UN3291, Regulated Medical Waste, n.o.9, T8Z1 - t3d T o ( cu t <br />5,2, PGiI <br />Gu Fl. <br />W <br />UN3291 Aegulalmmedulwaste,n.o.T. T015 - 20 ®al tub Vatl)) (2,7 Cu St) <br />W <br />6.2. Poll <br />Cu Ft. <br />629PGI��gutaledMedltalWasle,n.o.6_ %Y15 _ 20 Gal sub (Chaao) 42.`i au Et) <br />Cd EL <br />Regulated M�M81 Wasle, n.o.0. <br />6 232911 <br />CU F l. <br />110291Regubled Medical Waste, n.o.g., <br />®.21 Pali <br />Cu Ff. <br />Phd CRIACeM40a1 WAS!1 <br />CuF. <br />3. eenerstoea Cenlffcallort:'I hereby devere that the oonlenl8 of this consignment are I'vi y and accurately T®TALS ® fz Cu 51, <br />described above the proper shloping name, and are classified, pacmged, marked and laboila4lacard and <br />are in all respects proper condition for iranspon aocolding to applicable International and national governmental regulations,' <br />In <br />X :PrintedAypad Name JqA i�' Signalure Oale + <br />4. TRANSPORTER t ADDRESS: Fhone ll: - <br />stericycle, Inc. ❑ This is a Thcough Shipment <br />Appllca armisN: <br />4135 We-3tSwiftAve. Reuutl er Reegig# <br />.3900 <br />irresno,ca 93722 <br />TRANSPORTERRTIFICATION: �' IPI of dial wasto as described a J <br />Prfm/rype Name Signature Date <br />5. INTEHMEOIATE H DLER j-/ TRANSP FiTER 2 ADDRESS: Phone 0: <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION; Rmelpt of medical waste ae descrlbod above. <br />Prinl a Name Signature 0318 <br />0, INTERMEDIATE HANDLER 3 /7RANSPOATER 3AODRESS: Phone 0: <br />Applicable Permll Numbers: <br />INTERMEDIATE HANDLER !TRANSPORTER CERTIFICATION: Receipt of medlcal waste as described above. <br />PrinIfType Name Signature Dale <br />?.DISCREPANCY IN131CATION <br />TlransfelTed comainers, cu to -Norm Sad Lake, UT <br />4. oealgnated declllty. 98. Aparnet& Faelltty: 00. Anemote Peetlity. eb.Altomata Fuehltyt <br />Sterleyd® InC-AUWdtsvo Stertgrcle Incl- Indrterallan Sted ydo Ino -Autoclave Stedcyde Inc-Autodtave <br />41 <br />135 W SWFI'AVE M NCIRTH 1100 WEST 1346 D80tNtie DrIve Sts C 2775 E 28TH STREET <br />t <br />FRESNO,CA 93722 NOM SALT LAKE CIN, UT Sttn Leandro, CA 94677 VERNON, CA 90023 <br />(659) 27 S - 1121 (MI)M&- 1555 (61 D) $62 - 217' (323) 362 - 3000 <br />TS/l'U3T2Z 3A -44S -JA -36 T'931/MOSTZ TWOS- 28 <br />.s. <br />DA F <br />TREATMENT FACILITY: I cerllly that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above indicated wastes In accordance with the requirement outlined in that authorizatlon. <br />MEC 2 o 2011 signature Date <br />Pnnt/lype NA <br />Received Time—Sep, 28,2012— 4;14PM—No. 0281 - IDR1GINAL <br />rpl(4atan itrwe-part t <br />