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®®. Stericycle' A&CASE OF EMERGENCY CONTACT: CHEMTREC 1-80"24-,319k <br />• ^`°"®"'*� "'�Od CUSTOMER NO. 211 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST oot-i""TO <br />iTii7 •i +T1Ta>F `1 i+l'� � <br />` .YET . 1 •. � <br />1. Generator's Name, Address and Telephone Number <br />AWN: <br />MOTON CARE CENTER <br />442 E. EWTON ST <br />STOCKTON, CA 95204 <br />209 466-0456 <br />5/10/2011 <br />CUStoMM NMSM GENMArows REGStRATION • <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINER TYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3291, Regulated Medical Waste, nvs.. <br />CONTAINERS <br />6.2, PGB <br />TB57 - 90 Gal 'Pub (Bio) (12 cu ft) <br />Cu FL <br />UN3291, Regulated Medical Waste, n.os., <br />6.2, PGII <br />- 37 Gal Tub (Rio) (4.9 Cu ft) <br />Cu Ft. <br />®UN3291. <br />Regular Medical Waste, n.o.s., <br />66 <br />TH14 - 44 Gal Tub (Bio) (5.9 Cu ft) <br />Cu Ft. <br />6.2. 291.POP Regulated Medical Waste. n.o.s., <br />TB21 - 20 Gal Tub (Bio) (2.7 cu ft) <br />Cu Ft. <br />W <br />UN3291, Regulated Medical Waste, n.o.s., <br />IZ <br />6.2, PG If <br />TB15 - 20 Gal Tub (Path) (2.7 cu ft) <br />Cu Ft. <br />ON3291Regulated Medical Waste, n.o.s., <br />6.2, PGIi <br />TY15 - 20 dal Tub (Chemo) (2.7 cu ft) <br />Cu Ft. <br />UN3291. Regulated Medical Waste, n.o.s.. <br />6.2, PGII <br />Cu Ft. <br />UN3291. Regulated Medical Waste, n.o.s., <br />62, PGII <br />Cu Ft. <br />Cu Ft. <br />3. Generator's Certification: `I hereby declare that the contents of this consignment are fully and accurately TOTALS ► <br />C Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelledrplacarded, and <br />are in all respects in proper condition IA transport according to applicable international and national governmental regulations.* <br />,'e <br />r / <br />XPrinted/Typed <br />Name Signature <br />Date <br />4. TRANSPORTER 1 ADDRESS: , <br />Phone <br />559)275-1121 <br />ui <br />Steri&ycle, Inc. ❑ This is a Through Shipment: <br />Applicable Permit Numbers: <br />t o <br />4135 West Swift Ave. <br />Hauler Reg# 3400 <br />y <br />Fresno, Ca 93722 <br />4 d <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described <br />~ <br />Print/Type Name _AkSignature <br />Data <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone <br />N <br />5 m <br />Applicable Permit Numbers: <br />wm <br />ca <br />RIZ <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: described <br />Receipt of medical waste as above. <br />Print/Typo Name Signature <br />Date <br />M <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone 9: <br />c o cc <br />Applicable Permit Numbers: <br />g a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrintlType Nam Signature <br />Date <br />7. DISCREPANCY INDICATION <br />Transferred containers, all ft to : North Sift Lake, UT <br />A. Designated Facility: 118. Alternate Facility: E] 6C. Alternate Facility: <br />80, Alternate Facility: <br />Z:31 <br />Stertcyde Inc -AutDchm Ster��de lno� Incineration Ste Inc A <br />Inc-Autodava <br />2775E 26TH STREET <br />4135 W. SY41i TAVE 90 NORTH 11001+VEST 1345 t7aoUtde Dtive Ste C <br />u. <br />FRESNO,CA 93722 NORTH SALT LAKE CITY, UT San Leandro, CA 94577 <br />VERNON. CA 90023 <br />Z <br />uI <br />(559) 275 - 112,E O ($0 t) 936 - 1555 (510) 562- 2177 <br />(323) 362 - 3QD0 <br />TS/OST-26 <br />TS/0ST22 DA tpvED 3A -448 -JA -36 TS31)TS/OST25 <br />TREATMENT FACILITY. I'_certi�ithat I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />h <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />Print/Type Name `A Signature <br />Date <br />` .YET . 1 •. � <br />