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10/25/2010 14:34 FAX 2098390799 IM0006/0009 <br /> 10/15/2010 17:01 Remote ID I int ID ,_ _ ` _ D 2/5 <br /> MEDICAL WASTE TRACKING FORM NU EI <br /> ®®0 starkyder IN CASE OF EMERGENCY CONTACT:C1EMTREC 14WZMMI STANDARD MANIFEST 001-io-0o-STD <br /> ••• — Route #: 809 -20 MEISN00HA21li <br /> 1.Generator's Name,Address and Telephone Number ( N <br /> A : Carman tt {tjt <br /> DAVl''A <br /> 425 BEVERLY ST STE A <br /> ,MACY, CA 95376 <br /> 11209) U39-0398 11/16/2005 <br /> CUSMUER NUMMM 6018152-005 CeamPATcamRoGa <br /> 2n_DESCRIPTIOSI OF WASTE 219. 2C. NO.OF 20. VOILUM <br /> REGULATED MEDICAL WASTE,no.s.A2 2857 - 90 Sal Tub (21o) (12 aw irt) CONTAINERS <br /> UN 3291,Ps If Cu F <br /> REG <br /> ULATEOMEDICALWASTE,n.os.AZ TH14 - 44 Gal Tub(DiO), CT 13.'/ lb IS. cu Et} <br /> LIN t PG II Cu F <br /> CC REGULATED MEDICAL WASTE,rms.,6.2, T821 - 20 Gal Tub (Si o) (Z.7 cta ftp <br /> ® UN 3291,P611 cup <br /> Q REGULATED MEDICAL WASTE.nos,6.2 - a o <br /> lZ UN 3291,PG 11 Cu F <br /> W REGULATED MEDIrAL WASTE.n.os.A.2, TB15 - 20 Gal Rub (Bath) (2-7 cu ft) <br /> W UN 3291.PG 11 Cu P <br /> 0 REGULATED MEDICAL.WASTE rt.os.,6.2, 7Y15 - 20 tial Tub fchcma) (2.7 cu ft) <br /> UN 3291.PG 11 Cu Fi <br /> REGULATED MEDICAL WASTE,n.os.,6.2 2'H35 - 26 (ia1 Tub (Rio) (3.5 cu it} <br /> UN 3291.PG 11 Cu P <br /> REGULATED MEDICAL WASTE,n.os.,6.2. <br /> UN 3291,PG ti Cu FI <br /> L. <br /> 3.GeneraWa Ce lon:N hereby dere ghat the contents of this consignment are fully and accurately TOTALS ► a Cu FI <br /> described aboova by the proper shipping name,and are classified,packaged,marked and la acwded,and <br /> are in al respects in proper conlowNlor rt n to applicaW kdernational and national governmerMat ns' . <br /> • Name SI re Date <br /> 4.TRANSPORTER t ADDFgW Phone o <br /> St3r1 a Inc <br /> Applicable Pern�Numbers: <br /> g H <br /> rm DR <br /> Th <br /> SAN Cir CA 4857 This it; b Through Shipment' <br /> 4 a TRANSPORTER C : R of m waste as described <br /> Q 4 <br /> ~ Print/Type Nance Signahxe Date <br /> 5 INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone S: <br /> steeicyele, inc 1345 Doolittle C San 'Leandro, CA 94577 Applicable Permit Numbers: <br /> S <br /> INTERMEDIATE HANDLER/TRANSPORTER CE ICATION: Receipt of medical waste as described above. <br /> PrinVTypo Name Signature Date <br /> 8.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone N: <br /> NJ <br /> Applicable Permit Numbers: <br /> m a <br /> INTEMEDIATE HANDLER ITRANISPORTER CERTIFICATION: Receip or medical waste as described above. <br /> fE PdWlype Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> T ai rs, 0 to : MOM SO lake,111' <br /> > g FWKr. Facility: ®8C.Aftmole Facility: 80.Aftnvxb Faellitr, <br /> 3 ndrieradon <br /> C 3140 Inc'Sit Inc.A ,30 11(10 I <br /> 4132 Yy.S�vi1!Av9nuewas <br /> 4 ®an LoewoetroAA Q4677 K Ctby.KC =i is Praauw.CA 93722 North Sat.Lake Clty.UT 64054 <br /> i"- 1510)so-1781 (2113)321 - 1 1559)275-OW 180112316- 1555 <br /> LU <br /> T~a31,YWOST26 EPA# K 52892612 C V I rt � on P-6,P-115 <br /> Per 81-02 <br /> a <br /> W TREATMENT FACILE cepAy that I have been authorized by the a state to accept untreated wastes and that I have <br /> 11-- r thea 1 (es in accordance with the requir o n. <br /> o <br /> Ptintlrype Name signator® Dow 140V 16 2009 <br /> c <br /> OR <br /> IGT 1. rplldenaa�Sa�tabtd tz-g +zw4 <br />