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10/25/2010 14:33 FAX 2098390799 IM0005/0009
<br /> 10/15/2010 FRI 12: 56 FAX 0 IMD02/002
<br /> ........ ir-i*.-AL WASTE TRACKJINQ FORM NUMBED
<br /> Sterkycle' &C TEAR 11EA sTANoAF%DmANu;ES'rooi-iO4"T0
<br /> UTE Of EM§r
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<br /> loom.6 P.9YC1 MDFR009ZIO
<br /> ft*kctWgPt4pk kdudaOML
<br /> i—.a—A'arator's Name,Address and Telephone Number
<br /> ATM.- Carman
<br /> [)A-vl T16.
<br /> 425 B ZYM1LY ST STE A ACCDW j.. 60I8152-005
<br /> Poavita
<br /> TRACY, CA 95376 SM IM OAIE: joI5110 7:46:07 AM
<br /> GRIO ID: R81
<br /> STIi�iF4'i titE:( a: 21O
<br /> CUSTOMER NUMBER 6018152-005 TOTAL COLIECiED: 12
<br /> Co: TOTAL VWK: 70.8W CO F1 2A.DESCRIPTION OF WASTE 2B. M. NO.OF 21). VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., TB57 90 G&L Tub ooAojffi T814 !riA'j!q11,
<br /> R —41:1 CONTAINERS
<br /> 6.2,PGII !6 14 Cuf mt�'0.-
<br /> TCq oWIRT T814
<br /> UN3291,Regulated Medical Waste,n.o.s." T3q9 37 9-al. Tub (310? j(jj.i OoAOIRN 1514 1514
<br /> 6.2,PGII likOV1,19f B14 WMIFJZ 1814 KA4 Cu I
<br /> 6.NRegulated Medical Waste,mo.s.' TBYL4 44 Gal ruio (41
<br /> C UM1 -2,PH
<br /> UN3291,,Regulated Medical Waste,n.o.s., We"1 20 wax TXW(11110 -_WW([01a type) QIY CI.WL Mr�c-
<br /> 6.2,PGII , Cut
<br /> .Y0
<br /> U UN3291,Regulated Medical Waste,ri.os., TJ—US ZU) q,41 !1T7AU (Pahl) T814 44 6i Tuh(Bilo), ET 12-3 2
<br /> 71 6.2,PGII Cut
<br /> U UN3291 TY15 20 Gal Tub (Chen*)( . lit""y'a1yW
<br /> 6.2.PGI!
<br /> Regulated mairical Waste,n.os., Cu I
<br /> UN3291,Regulated Medical Waste.n.os.,
<br /> 6.2.PGIJ Cull
<br /> UN3291,Regalated Medical Waste.n.o.s.,
<br /> 6.2.PGII Cul
<br /> Pharmaceutical Tilaste
<br /> 3.Generator's Certification:'I hereby declare that the contents of this consignment are tully,and accurately
<br /> described above by the proper shipping name,and are classified,packaged.marked and labell carded
<br /> are In all respects in proper condition for transport according to,applicable international and national governmental regulations."
<br /> APrinted/rNam % Signature
<br /> 4,TRANSPORTER 1 LtDDREISSS., V Phone
<br /> Applicable Permit Numbers;
<br /> 4135 Bast Swift Ave.
<br /> 0 -21,peano,Ca 93722 0 This is a Through Shipalent
<br /> TRANSPORTER CgRTIFICATION:PAci bove,
<br /> &. rwtue
<br /> Date PriwTypa NaT!,j=:;
<br /> S.INTERMEDIATE HA TiLER 2 TRANS 29bAESS: .7. V ' Phone
<br /> Applicable Parmh Numbers:
<br /> Its
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION.Receipt of medical waste as desalb6d above.
<br /> PflntfType Name Signature Date
<br /> 6.-INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone a-
<br /> ge Applicable Permit Numbers:
<br /> a
<br /> ZZ
<br /> wig
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> IC4
<br /> lux
<br /> Print/Type,Name -Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> emahwo, cu A to : NOM Soft Lake,UT
<br /> VIA.Desigmted FacillW. E]89.Alternate Faclllty: 0&C.Alternate Facility 0 81).Alternate Facility-
<br /> Ste dcyde Iric:-Autodave swnwde Inc-tridneradon S*rlcyde InC-AlftdaW SbKiqde Inc.-Aulmdirm
<br /> 4 j 35 W.SWFT AVE 90 NORTH 1!00 WEST 1345 D0000 DO"SW C 2776 C-267H STREET
<br /> PPEW40.0k 93722 NORT14 SALT LAKE 07Y,UT SW LeWdiv,CA S4577 VERNON,CA SM2
<br /> 3
<br /> (5591,275-09% (Sol)S3&- I Boo (6 10)562- 1781 (323)362-3=
<br /> TS31.TWOST25 TSIOST22 Cim V IndnemIkift PeMW 81-02 P-6.P-I 16
<br /> TREATMENT FACILITY; I certify that I have been authorized by the applicable s to age accept untreated medical wastes and that I have
<br /> received the above inds in accordance with the requirement in th rization.
<br /> Print/Type Name Signature Date /0 -
<br /> '1C=ArRff=&rr CAMF[TV
<br />
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