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MEDICAL WASTE TRACKING FORM NUMBER,i <br />®• Stericycle' CASE OF EMERGENCY CONTACT: CHEMTREC 1.800.42 STANDARD MANIFEST 001.10.06•STD <br />— ®• Fr.t.ctM17 haply Rei,dnR Rick: <br />"Wroute #: 100 - 12 Customet: iso.032 MDFROOA4TJ <br />a <br />1. Generator's Name, Address and Telephone Number <br />A: <br />I I milli <br />JAMMN CARE cENTER <br />442 E. MUCMIR ST <br />MCR'1i01, CA 95204 <br />(209) 466-0456 <br />11/9/201( <br />AC <br />CUSTOMER NUMBER 6080852-•00y 1 GENERATowsREGISTRATION I <br />2A. DESCRIPTION OF WASTE <br />2B, CONTAINERTYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3297, Regulated Medical Waste, n.o,s„ <br />6.2, PGII <br />T857 - 90 Gal Tub (73i0 (12 Cu tt) <br />CONTAINERS <br />Cu FL <br />6 231`111' Regulated Medical Waste, n.o.s., <br />37 Gal Tub (Bio) (4.9 cu tt) <br />fr CU FL <br />CC <br />® <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, P(311 <br />- 44 Gal Tub (Hio) (5.9 Cu tt) <br />Cu FL <br />04 <br />UN3291, Regulated Medical Waste, n.o.s., <br />TB21 20 Gal Tub (Bio) (2.7 cu tt) <br />6.21 PGII <br />Cu Ft. <br />W <br />W <br />UN3291, Regulated Medical Waste, n.o.s.. <br />6.2, 1`011 <br />T815 <br />7815 - 20 Gal Tub (Bath} (2.7 Cu ft) <br />Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PG I) <br />7Y15 - 20 Gal Tub (Chemo) (2.7 cu ft) <br />Cu Ff. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291Regulated Medical Waste, n.o.s., <br />6.2, PGii <br />Cu Ft. <br />PbaCmaceutical Mantel <br />Cu FL <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®TALS ® <br />1 Cu FL <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations" <br />Printed/typed Name LA-� 1gnature <br />Date <br />4. TRANSPORTER 1 ADDRESS: '` - <br />Phone l: (559) 275 - 0 <br />Stericycle, Inc. <br />Applicable Permit Numbers: <br />4135 test Swift Ave. <br />Th <br />This is a Cough Shipment2 <br />` <br />0. <br />Fresno, Ca 93722 <br />,•_ <br />CL <br />TRANSPORTER�CERTIFICATION: Receipt of medical waste as described <br />pZ <br />PrintfType Name Signatur i--�" <br />Date 1 <br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: ' ` <br />Phone I: <br />s <br />Applicable Permit Numbers: <br />¢ <br />• <br />Rio <br />in <br />IF, <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described ai o;: <br />• Kms.: <br />Print/Type Name Signature <br />► <br />Date <br />.n <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS_ ' •' <br />Phone I: <br />Applicable Permit Numbers: <br />R ¢ <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />a <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />to : NwM Soft Lake, UT <br />y. <br />Oasljinated Facility: 88. Altemate FaclUty: ® 8C. Altemats Facility: <br />811). Altemate Facility: <br />:3 <br />Shidytile Inc -Autigiclaw Ino- 1 Inc <br />Inc <br />V <br />4 t 35 W. FT AVE 90 N 11 1 Ile C <br />2775 E <br />triFRESNO.CA <br />93722 NORTH T LAKE CITY, UT . CA WWT <br />VERNON. CA 9=3 <br />(559)2755- OM (001) 9xi -1555 (510) M -1761 <br />( - <br />w� <br />TS3I. V t 91 <br />.1-115 <br />r <br />3 TREATMENT FACILITY: I certify that t have been authorized by the applicable state agencyaccept untreated medical wastes and that I have <br />received the above i s in accordance with the requirement outfi in the rization. <br />Nov M9 <br />Print/lype Name Signature <br />Date <br />}./7- <br />a <br />