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• MEDICAL WASTE TRACKING FORM NUMBER IN
<br />� .90 Stericycle' ASE OF EMERGENCY CONTACT: CH MTREC 11-800-234-0050STANDARD MANIFEST 001 -10 -05 -STD
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<br />IptF4atrearWGW 16 cw2m ORIGINAL
<br />1. Generator's Name, Address and Telephone Number����'���������
<br />AWN: Judy Jasperson
<br />tr iJ fJ
<br />SODEXO LAUNDRY SERVICES, INC
<br />7679 S LONGE STREET
<br />STOCRTON, CA 95206
<br />(209) 982-4955
<br />9/18/2009
<br />60 4 a 6 * 1- 0 02
<br />CUSTOMER NUMBER GENERATDR's REGISTRATION a
<br />2A. DESCRIPTION OF WASTE
<br />2a. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />TBS7 - 40 Gal Tub (Bio) {12 cu ft)
<br />CONTAINERS
<br />UN 3291, PG II
<br />Cu Ft.
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />TB49 - 37 Gal Tub (Bio) (4.9 cu ft)
<br />UN 3291. PG 11
<br />Cu Ft.
<br />CC
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />TB14 - 44 Gal Tub (Bio) (5.9 cu ft)
<br />Q
<br />UN 3291, PG 11
<br />I
<br />5 Cu Ft.
<br />Q
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />TB - 20 Ga 10 cu tt
<br />jr
<br />UN 3291, PG II
<br />Cu Ft.
<br />W
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2.
<br />TB15 - 20 Gal Tub (Path) 42.7 cu ft)
<br />IZ
<br />UN 3291, PG II
<br />Cu Ft.
<br />ar
<br />REGULATED MEDICAL WASTE,n.o.s.,6.2.
<br />TY15 - 20 eal Tub (Chemo) (2-7 cu ft)
<br />UN 3291, PG II
<br />Cu Ff-
<br />REGULATED MEDICAL WASTE. n.o.s.,6.2,
<br />UN 3291, PG II
<br />Cu Ft.
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />UN 3291, PG II
<br />Cu FL
<br />Pharmaceutical Waste
<br />Cu Fi- 1
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTAL,41
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<br />described above by the pro shipping name, and are classified, packaged, marked and labelled/placarded, nd
<br />are in all respects in proper ion for transport cording to applicable international and national governm tal re Ions"
<br />X+Printed/T'yped Name h Q--O-\Signature
<br />Dat - B d
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone a: (559) 275 - 0999
<br />W
<br />$teriC}rCle, Inc.
<br />CC
<br />4135 West Swift Ave.
<br />Applicable Permit Numbers:
<br />< a Fresno,
<br />Ca 93722 ❑ This is a hcoug shipment
<br />CC
<br />Q
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />~
<br />41Vl`—I
<br />Print/TypeName Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS:
<br />Phone k:
<br />{o{r{{�11 a¢
<br />Applicable Permit Numbers:
<br />ZiJ
<br />W O
<br />g¢i
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Typo Name Signature
<br />Date
<br />w
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone q:
<br />¢ r -
<br />Ia Ir
<br />a w
<br />Applicable Permit Numbers:
<br />C3
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />-
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Transferred oontainers, cu It to
<br />f
<br />7
<br />8A. Designated Facility: 88. Alternate Fectilty: ❑ 8C. Alternate Facility:
<br />8D. Alternate Facility:
<br />STERICYCLE INC STERICYCLE INC STERICYCLE INC
<br />STERICYCLE INC
<br />4135 W. SWIFT AVE 90 NORTH 1100 WEST 9053 NORRIS AVE.
<br />2775 E 26TH STREET
<br />a
<br />FRESNO,CA 93722 NORTH SALT LAKE CITY, UT SUN VALLEY, CA 91352
<br />VERNON, CA 9!1023
<br />(559) 275 - 0994 (801) 936-1555 (8 18) 504 - 6937
<br />(323) 362 - 3000
<br />LijZ1:
<br />TS31, TS/OST25 TS/OST22 Class V Incineration Perm191-32
<br />P-6, P-115
<br />Br
<br />a
<br />TREATMENT FACILITY: I that I have been by the
<br />�'
<br />certify authorized applicable state�7gency to ac�ept untreated medical
<br />wastes and that I have i
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<br />received the above indicate St accordance with the requirement outlig that a oeizat n.
<br />SEP 18 20D9
<br />/1 ,��� ✓ ��'`"<�
<br />Print/Type Name Signature
<br />Date
<br />IptF4atrearWGW 16 cw2m ORIGINAL
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