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MEDICAL WASTE TRACKING FORM NUMBER
<br />Stericycle' OCASE OF E VC`�COjPJT:SHIjIfREC 1400.23q* STQy�ytFA$j_ I0-06-STO
<br />r..i.awy w.p. r.m,aq N,,' PP�rII ll1J fit• ji t�t(/Hj
<br />tptROMW605zad 3484).2009 ORIGINAL
<br />1. Generator's Ner11 41(dreguylyJaS
<br />T�person on
<br />—IMMIMIUMEW
<br />SODEXO LAUNDRY SERVICES, INC
<br />7679 5 LONGE STREET
<br />STOCKTON, CA 95206
<br />(209) 982-4955
<br />10/2/2009
<br />' '�::.. ,_/ �. it •.
<br />6048671-002
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />REGULATED MEDICAL WASTE, n 0x.,6.2.
<br />TB57 - 90 Gal Tub (Bio) (12 cu ft)
<br />CONTAINERS
<br />UN 3291, PG II
<br />Cu Ft
<br />REGULATED MEDICAL WASTE, r1.o.s-6.2,
<br />"
<br />UN 3291, PG 11
<br />Cu Ft
<br />CC
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />0
<br />UN 3291, PG II
<br />_
<br />• Cu Ft
<br />Q
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />cc
<br />UN 3291, PG II
<br />Cu Ft
<br />W
<br />REGULATED MEDICAL WASTE, n o s.,6.2,
<br />Z
<br />UN 3291, PG II
<br />Cu Ft
<br />W
<br />0
<br />REGULATED MEDICAL WASTE, n.c.s.,6.2,
<br />-ZU Galemo cu
<br />UN 3291, PG II
<br />Cu Ft
<br />REGULATED MEDICAL WASTE, n.o s.,6.2.
<br />UN 3291, PG II
<br />Cu Ft
<br />REGULATED MEDICAL WASTE, n.o s-62.
<br />UN 3291, PG II
<br />Cu Ft
<br />Pbarmaceutdcal Waste
<br />Cu Ft
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully art ately . TOTALS
<br />JM Cu Ft
<br />l r and
<br />des ' above by the proper shipping name, and are classified, packaged, marked and tabrx-
<br />in all eels in proper condition for transport according to applicable international andrn ntal re tions"
<br />ull.,V—Typecl
<br />D
<br />Name 7 `
<br />ANSPORTER 1 $1?1&1!!�ftCle Inc. :.
<br />•^'
<br />Phone #: '
<br />LU
<br />9135 Hest Swift Ave. ? "=!
<br />Applicable Permit Numbers:
<br />°C
<br />❑ is• ;Throt�gli; Sli3pment
<br />p
<br />Fresno Ca 93722
<br />Mel z
<br />a 4
<br />TRANSPOR R : R m I was as describ abov �' 1' .t ycr
<br />~
<br />Print/Type Namgnature
<br />Date
<br />5. INTERMEDIATE H L R 2 /TRANS TER 2 ADDRESS_
<br />Phone #:
<br />5
<br />Applicable Permit Numbers:
<br />w
<br />U)CI:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described abovo.t'
<br />Print/Type Name , Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />W4 w
<br />Applicable Permit Numbers:
<br />0
<br />3-,r a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />z�x
<br />—
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Transtermd corrtaitters, CU ft to
<br />FFS
<br />8A.Deslanated FacuAlternate: 88. Alternate Facility: Fac• C] ac atit 80. Altemate adlity:
<br />SIMICY= INC STERICYCLE INC S �?IL�YCL INC STERIG�YCLE INC
<br />L9L9L9
<br />a
<br />4135 W. SIM IT AVE SO NORTH 1100 WEST 9053 NORRIS AVE,
<br />93722 NORTH SALT LAKE CITY, UT SUN VALLEY, CA 91352
<br />2776 E 213TH STREET
<br />VERNON, CA 90023
<br />FRESNO,CA
<br />(559) 275 - 0994 (80 1) 936 - 1555 (818)504-6937 .,
<br />(323) 362 - 3000
<br />H
<br />TS31, TSIOS T25 T SIOST22 Class V Inclneradori Pelt# 91 02 P-6. P-115
<br />41
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to aXppt untreated medical wastes and that I have
<br />received the above indicated to ' accordance with the requirement outlined ' t aut on.
<br />OCT �QQg
<br />Print/Type Name ignature
<br />Date
<br />nen-- ,-,
<br />zi
<br />tptROMW605zad 3484).2009 ORIGINAL
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