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10/25/2010 14:33 FAX 2098390799 IM 0004/0009 <br /> 10/15/2010 16:50 Remote ID I int ID _ D 2/3_ <br /> - ~ MEDICAL WASTE TRACKING FORM NOME <br /> ®® 5tetr iN CASE OF EMERGENCY CONTACT: C 14006424-93M STANDARD MANIFEST 001-10-06-STD®® �.• Route 4: 318 - 5 NDFROOSIVY <br /> 1.Generstor'S Name,Address and Wephone Number <br /> ATTN; Carman <br /> DAVITA <br /> 425 BLVERLY ST STE A <br /> TRACY, CA 95376 <br /> (209) 839-0398 8/17/201( <br /> cusromm Nusnom 6018 52-005 'r' <br /> ZA.DESCRarnom OF WASTE 26. CON11AINERTYPE 2c NO.OF 2D. VOLUME <br /> UN3291,Regubted Medical Waste,n.cs., CONTAINERS <br /> 62,Phu T857 - 90 Cal Tub (Bio) (12 cu ft) Cul <br /> 623PG11 Regula Waste,n.o,s, T8 9 - 37 Cal Tub (Bio) (4.9 cu ft) <br /> Cul <br /> Q SUNN3229911,Regulated Medical Waste.n.os tTHl! $4 Gal TLA($1O) (5.4 cu fit) ® ® Cul <br /> Q UN3291Regulated Medical Waste,n.o.s., TB2L - ZO (Ml Tub(Blo) (2.7 cu tt) <br /> 62,PGti <br /> Cul <br /> UJ UN3291.Regulated Medical Waste.FLO.&. <br /> IZ S.Z PG11 Tais - 20 Gal Tub (Rath) (2.7 cu Et) cul <br /> s PGIIRegulatedRulated Medical wade n os., TY15 - 20 Gal Tub (chemo) (2.7 cu ft) Cul <br /> UN3291 Regulated Medical Waste,n.O.s., <br /> 6.4 PGd --Cu F <br /> UX 91 Regulated Madicid n.os.. ,a Cu F <br /> RhacnamurjCa2 Ste I TA <br /> 3_Generatoes :-I hereby declare Nat the contents of this consignment are fully and accurately TOTALS 0- , <br /> above by the r shipping and are fie 1, and and <br /> Am n <br /> espects In proper tion for transport acoDrding to applicable internationaln meetmf ns- <br /> tedlT Name ® Date -I Ito <br /> SPORTER 1 ADDRESS: Pffhe 8: (559) 275 - 0 <br /> Stericycle, Inc. Appliamble Permlt Nurabow. <br /> 4135 Nest Shrift Ave. This is a Through Shipment <br /> ME z Fresno,Ca 93?22 <br /> 4< NS RCE FICATION: Receipt of ntedFsal wage as do <br /> r <br /> /®-71 <br /> Prim/Type Nww IT Signature Dat® <br /> s.INTERMEDIATE HANDLER /TRANSPORTER 2ADDRESS- Phone M: <br /> C Applicable PernA Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> 6.INTERMEDIATE HAWLER 3/TRANSPORTER 3 ADDRESS: Phone a: <br /> r3 Applicable Permlt Numbers: <br /> AINTERMEDIATE N /TRANSPORTER CERTIFICATION: Receipt of rnedioai waste as deserted above. <br /> t: <br /> — Print(Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Tranfbind ala*l% R to Hadh San LaM,UT <br /> r SA 86,Atmn FadW; Lj 8C.Alternate Facility: U 80.Alternate Faculty: <br /> SWrIcoe Inc-Autodave MedaVdeIno-Indna Steftcle Inc-AuWdave Stedcyde Inc <br /> 4135 W. FTAVE 80 NORTH I IOU WEST 1345 DooMe Drtve Ste C 2775 E 26TH STREET <br /> L <br /> FRESNO.CA 93rn NORTH SALT LAKE CITY.UT San L8 V ON,CA WIM <br /> u <br /> (m)275- ( 1)938-1555 (St a) - 1701 (323)362-3W0 <br /> TS31,TSJOST75 TWOST22 CI=V Incineration PemrW 91 02 P-$.P-115 <br /> EWILSON <br /> TREA ENT FACILITY: 1 cerW that I have been authorized by the appl' e a to accept untreated medical wastes and that I have <br /> received the above indicated wastes in accordance with the requirement outilneRT—Iff that authorization. <br /> Print/Type Name signature At IC 2 6 2010 Date <br /> Q O 8 Q 5 <br />