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10/25/2010 14:34 FAX 2098390799 IM0007/0009 <br /> 10/15/2010 17:01 Remote ID Sint ID _ _ D 3/5 <br /> :1 •0. MEDICAL WASTE TRACKING FORM NUMBEF <br /> 000 Steritytlle' IN CASE OF EMERGENCY CO, ;Cts 1-N0-234.0051 STANDARD MANIFEST 0al-io-w STD <br /> 0 Route #: 8U9 16 MDSNO(1H4U8 <br /> 1.Generator's gCar�on <br /> Nae,Address: Tel vne Number <br /> DAvxTt1 <br /> 425 BEVERLY ST STE A <br /> TRACY, CA 95376 <br /> (209) 839-0399 10/26/2003 <br /> . 6 <br /> NUMBER 6018152-005 Rtienrrvuvrm• <br /> 2A.DESCRIPTION OF WASTE 20. CONTAIWER TYPE 2C. NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,n.os.A 87 - 90 (810) (32 au 90 CONTAINERS <br /> UN 3291,PG II Cu Fl <br /> REGULATED MEDICAL WASTE,n.os..6.2, T014 - 44 Gal Tub(Bio), CT 12.7 lb (S.9 cu !t) <br /> UN 3291.PG 11 Cu Ft <br /> Q REGULATED MEDICAL WASTE;n.o.s.,S.2 TD21 - 20 deal Tub (Dio) (2.7 Cu Lt) <br /> UN 3291.PG it Cu FI <br /> Q REGULATED MEDICAL WASTE,n.os.,6.2, - Ge xo , cu <br /> UN 3291,PG II ° Cu Ft <br /> WREGULATED MEDICAL WASTE.mo.s.,S.2, IBIS - 20 Gal Tub (Path) (2.7 Cu tt) <br /> UN 3291.PG II cu R <br /> C9 REGULATED MEDICAL WASTE,mos.,6.2, Ty15 - 20 Gal grub (Chemo) (2.7 cu tt) <br /> UN 3291,PG 11 Cu Ft <br /> REGULATED MEDICAI.WASTE,n.os,6.2, T$35 26 tial Tub (Elio) (3. au ft) <br /> UN 3291,PG II Cu Ft <br /> REGULATED MEDICAL WASTE,n.os.,6.2, <br /> UN 3291,PG It b Cu Ft <br /> My) gg Ft <br /> 3.Generator's :1 hereby declare that the contents of this consignment are fully and accurately TOTAL$ Cu Ft <br /> described above by the proper shipping name.and are classSfedpackaged,marked and labelled/ ed,and <br /> are in all respects in proper condition for Ira acoording to applicatges international ational governmental regulations; <br /> • <br /> ® yped Name Skanature -rA, or,4k7�- <br /> Date <br /> 4,TRANSPORTER 1 ADDR. Phone 9: d <br /> W SterlCycle IRC Applicable Permit Numbers; <br /> 9® 136�i-UQOI,1`t"1`1,E UR This is a Through Shipment <br /> N SAN RO,CA 94577 a e TRAN CE F'! TION: Rocoipt of mcclicai wast4 md abme_ <br /> a <br /> }' Printr ype Name Signature Date <br /> 5.tNTERMEDIATE HANDLER 2/TRANSPORTE:R 2 ADDRESS: Phone#: <br /> Stecicycle, inc 1345 Doolittle C San Leandto, CA 94577 Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER C 71FICATION:Receipt of medical waste as described above. <br /> Name Signature Date <br /> w 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phase# <br /> S= Apptk:nblo Pormh Numbers; <br /> ;w9 <br /> RE1 M TE R/ ANSP® R C CATION:Receipt of m I waste as described above. <br /> PrinVType Name Signature Data <br /> 7:DISCREPANCY INDICATION <br /> Tmnsferredocifflainers, tai A to : North San(01(6,UT <br /> y tkDesi 0&Afternaft Fscllltif8C.Alternate Facility: �. Fadlt)r; <br /> 3 r9 .IftG A de•Ina. 6" .Ifit:.A Steri°/de,Inc.Incineration <br /> 1346 @ C 3t40 N 7th StT11WV 4182 W. Avenue 90 North 1100 VVest <br /> J oma+Loovndro.CA 94677 Kuncem cam,ttS 66116 Prdtirw.CA 83=2 Noah Salt Lake CRY.UT W154 <br /> ® <br /> (5 It)562- 1781 (913)321-1 (558)275-0994 (201)936- 15S5 <br /> ztt '1`331,TwOST25 TEPA* K 900528926 f 2 Class V Incineration P-6,P-11;5 <br /> E P® 91-02 <br /> Q , <br /> L <br /> TREATMENT�ab <br /> FACIL I t: that 1 have been authorizedby the a e to accept untreated medical wastes and ftt I have <br /> - received the Ica sates in ance with the requi to U V n. <br /> Printrrype Name �RECEIVED <br /> OCT 2 0 ZM9 <br /> 0 0 G a' Z MEDICAL WA5?t% <br /> ORIGINALeptf4e 1 [G!k! <br />