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To: .Sep. 28. 2012 4:03PM
<br />dee Stericycle'
<br />2012-08-21 18:11:52 COT No. 45549-1 P, 5 cu.tomer Care
<br />MEDICAL WASTETRACKING FORM NUMBER
<br />IN CASE OF EMEROENCV CONTACT: CHI:MTREC 1.600.42493M STANtARO MAKWEST oortoos5TD
<br />Route 0: 100 13 CUSTOMER NO. 21132 INOFROOBSKF
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<br />Received Time—Sep, 28.-2012` 4':14PM"No. 0281 ORIGINAL I
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<br />1. Generator's Name, Address and Telephone Numbep
<br />1111111111011111111AWN MCI
<br />EAMPTON CARE CENTER
<br />442 X. lt1WTON ST
<br />sTOC1C'IbP, CA 95204
<br />(209) 4660456 12/27/2011
<br />el,mraHEANUY9ER 6080852^001 Gox>:aainR-tR6erMAttON6
<br />2A, DESCRIPTION OF WASTE 28, CONTAINERTYPE 2C. NO. OF 20. VOLUME
<br />t1N3291 Regulated Medkal Waste, n,0,5•. TB57 - 90 Gal Tub (13io' (L2 au! fti CONTAINERS
<br />6.2, P G I I Cu FI.
<br />UN3291 Regulated Medical Waste,n.o.s., qg 77 Gal Tun (Rio) (4.9 cu tt)
<br />e.2. P411 Cu Ft.
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<br />UN3291IRepulatedMedical WWo,n.o.s., 019 44 Gal Tub(Vio) (S.9 cu ft)Fp
<br />6.2. Poll Cu R.
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<br />UN3291. ftUlated MedlmlW-- n.o.s., TB2 L - 20 Gal Tub (Bio) (2.7 cu t)
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<br />6,2, PGII Cu Ft.
<br />W
<br />UN3291,1`1e9111aledMedlealWas%n.0.5.. 1015 - 20 Gal Tub (Path) (2.7 cU It)
<br />Z
<br />6.2, PGII FI.
<br />UN3291.ReovlaledMedical Waste, n.o.s., '.1'X15 - 20 Gal Tub (Chemo) (2.7 Cu tt)
<br />6.2, PG [I Cu FI.
<br />UN3291 Regulated Medical Wads, n.os.,
<br />6 2, PGI I Cu FI.
<br />UN3291 Aeoulated Mil teal Waste. n.o,a,
<br />6.2, PGII Ou FI.
<br />Phasmaoltutical Hast
<br />9. (ioneratoes Certitfcatlont,i hereby declare ftl the oontente of thia consignment are fully and accurately TOTALS I► , Cu Ft.
<br />descrlbea above by the proper shipping name, and are 020fled, padkagoo, markod ane labeliearplacarded, and
<br />are in all respects in proper condition for transport according to applicable International and national governmental regulations`
<br />I IPrtnted/ijfpedName �t�� ��it�%7�./?/'`- __---Signature Qdl
<br />4.TRANSPORYER 1 ADDRESS: Phone 6: 5275-1121
<br />Stera.cyalea, Inc. ® This in a '1heough SlitiptaentApplicable Permit Numbers:
<br />41135 Hest Swift Ave. Hauler Rego 3400
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<br />Fre:3no,Ca 93722
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<br />TRANSPORTER C TIFICATION; Racetptot maefical wasto as do a //
<br />Prot a Namb Signa ure Oat® r(
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<br />S. INTERMEDIATE HANDLER 2 / NSPOR'rER 2 ADDRESS: phone o;
<br />Applicable Permit Numbers;
<br />S
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pi1nt/Type Name 9tgnaturo Dale
<br />e. INTERMEDIATE HANDIER 3 /'TRANSPORTER 3 ADDRESS: Phone e:
<br />gig
<br />Appflcable Permit Nurnberas
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION., Recalpt of meaisl waste as described above,
<br />PCrnlrrype Name Signature pato
<br />7.0ISCREPANGY INDICATION
<br />Tranderred Corri81nerS, CU It 10 : North Sah Lake, UT
<br />y�InIA.Allignaled
<br />Facility: 88. Attomalo Focllitrc 8C, Altamaw Facility. p ID. Altam+de Facility;
<br />EE
<br />5tertcyde Inc •Autodave S%ftde Incl, Incineration S9rl 0@ inc•A(Rodave Seri a Inc-At�dave
<br />E 2M MM
<br />4135 W. VW11"T AVE 90 NORTH I i (M MOT 1945 CiooMA9 00ve SU Q 2776
<br />FRIrSNO,CA 93722 NORTH SALT LAKE QTY, U San Leandro, CA 94577 VERNON, CA 90023
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<br />(559) 275. 1121 (849) 936- 1655 (6 10) $62_ 2177 /3231362 - 39]00
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<br />11S/OST22 3A -448-.1A-36 TS3IfraOST25 Tgf03T-P28
<br />DALE ANNE ORTIZ
<br />YREATMENT FACILITY; I oertify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the abFo(v�e Inndi ate asles In Accordance with the requirement outlined in that OULhorization.
<br />j`
<br />Prt veypo Name`-" Signature Dalo
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<br />Received Time—Sep, 28.-2012` 4':14PM"No. 0281 ORIGINAL I
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