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MEDICAL WASTE TRACKING FORM NUMBER <br /> a ®Q Stericycle* IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800-424kOO STANDARD MANIFEST 001-10.06-STD <br /> P„�,nvyr�p�R.d d�a�w Ro to#: 046- 5 CUSTOMER NO.21132 {�tDRCQ0tNPB <br /> 1.Generator's Name,Address and Telephone Number <br /> 312 SS FAIRMONT A�A 016 <br /> 11120/2015 <br /> k{ LODI,CA 95240-3848 (209)369-5418 <br /> I • <br /> CUSTOMER NUntaeR 60x3303-001, <br /> GENERATOR'S REWSTRATION# <br /> 2A DESCRIPTION OF WASTPc CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> UN3291 Regulated Medical Waste,nAs., CONT NERS � <br /> 6.2 Pali T814-(13io)/ 14-(Path)44 Gal Tub(6.9 t�l ft) COM <br /> 1 cit Ou Ft <br /> .PGH Regulated Medical Waste, <br /> 6.2 "'s” T821-(Sl#)/Tt1r54Path)/N � )1 Chemo 20 Gal Tub(2.7 <br /> 6.2, ) Cu Ft <br /> it 6.2Z,G1II Regulated Medical Waste,n o.s., Te4g-(E31o)/TP49-(Path)/TY48-(Chemo)37 Chat Tub(4.9) Cu Ft <br /> 62,GII Regulated Medical Waste,n.o. Q � <br /> CU Ft. <br /> W UN3291'Regulated Medical Waste,n.o.s., <br /> Z 6.2,PGII TE304-48 tial Tub(bio)(6.4 t3J ft) Cu Ft <br /> W <br /> 0 6.2,PG1i'Regulated Medical Waste,n.o.s., WW 1-031c)/WP314Path)/WC31-(Chemo)39 Gal Tub(4.94 cu ft) <br /> Cu Ft <br /> 6 2,PGII Regulated Medical Waste,n.os, WB43-(Bio)/PW43-(Path)/CW43-(Chemo)43 Gal Tub(5.7 cu ft) Cu Ft <br /> UN3291 Regulated Medical Waste,nos., <br /> 6.2.PGII KRB_-Biosystems Cardboard Box(4.2 cit ft) CU FL <br /> Cu Ft <br /> 3.Generatoes Certification:I hereby declare that the <br /> contents of flits consignment are fully and accurately TOTALS ® � � �®�a Cu Ft <br /> described above by the proper shopping name,and are classified,packaged,marked and labelied/piacarded,and <br /> are In all respects in proper Condi7Z� <br /> A acro g to applicable International and national gover auo <br /> ;X Printadfryped Name Signa Dale <br /> a 4.TRANSPORTE,.Ra,1IADDRESS: Phone# (866)783-7422 <br /> Sleficycle,Inc. This is a Through Shipment Applicable Permit Numbers: <br /> 14875 White Rock Rd 3400 <br /> M a. Rancho Cordova,CA 95742 <br /> CL 4 TRANSPOR CERTIFICATION:Receipt of medical waste as <br /> iS <br /> h' PrinSignatur pate <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#. <br /> a Applicable Permit Numbers <br /> a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above <br /> PrinMpe Name Signature Date <br /> e.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#• <br /> 5 Applicable Permit Numbers: <br /> x <br /> Ila INTERMEDIATE HANDIER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> a�x <br /> �— Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION Transferred Containers, Cas ft to. �Lake, <br /> resno, CA <br /> El Transferred containers, i tx f ft to Noror Fresno, CA <br /> �° ty <br /> �]8A.Designated FacI 86.Alternate Facility: 8C.Altemate Facfdiy SD.Alternate Facility: <br /> Q <br /> Stericycle, Ino. Stericycle, Inc. Stericycle, Inc. Stericycle. Inc. <br /> 1612 Starr Dr. 90 N.Foxboro Drive 4936 W. SvAft Ave 1661 Shelton Drive <br /> u- Yuba City, CA'95993', :s, North Saft Lake, UT 84054 Fresno.CA 93722 Hollister,CA 95023 <br /> (g16)g86=660h a (801)938-1171 (918)g86-6508 (860)783-7422 <br /> g TS/O *g . 3A 4481JA W MOST 22 TWOST 83 <br /> tX T R :;I1qerbfy that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> rtes in accordance with the requirement outlined in that authorization <br /> Prinwypeffl Signature Date <br /> Cq <br /> C? <br /> I <br /> ORIGINAL <br />