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MEDICAL WASTE TRACKING FORM NUMBER <br />• Stericycle' ASE OF EMERGENCY CONTACT: CHEMTREC 1.800.234.005 STANDARD MANIFEST 001.10 -06 -STD <br />nonnrq r.004. e,e,mq w: <br />Route 0: 301 - 13 <br />MDFR0081HK <br />k <br />I. %,enera>cors Name,erruGr <br />I{ <br />ATTN f JUdy Jasperson <br />SODEXO LAUNDRY SERVICES, INC <br />7679 S LONG STREET <br />STOCKf'ON, CA 9S206 <br />(209) 982-4955 <br />10/9/2009 <br />CUSTOMER NUMBER 6048671-002 GENERATOR's REGISTRATION s <br />" <br />2A. DESCRIPTION OF WASTE <br />24. CONTAINER TYPE <br />2C. NO. OF <br />20. VOLUME <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />UN 3291, PG 11 <br />T857 - 90 Gal Tub (Bio) (12 cu ft) <br />CONTAINERS <br />Cu Ft. <br />REGULATED MEDICAL WASTE, tt.o.s.,6.2, <br />g - 37 Gal Tub (Biu) (4.9 cu ft) <br />Cu Ft. <br />UN 3291, PG II <br />REGULATED MEDICAL WASTE, n.0.s..6.2. <br />T819 - 4 Gdl Tub (Biu) {S. 9 Ctl it) <br />r Cu FI. <br />Cr <br />Q <br />UN 3291, PG II <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />TB 1 __2 0 Gal Tub (aio) (2.7 cu ft) <br />Q <br />Er <br />UN 3291, PG II <br />Cu FI_ <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />TB15 - 20 Gal Tub (Path) (2.7 Cu ft) <br />W <br />UN 3291. PG It <br />Cu Ft. <br />C) <br />REGULATED MEDICAL WASTE, o.o.s.,6.2. <br />UN 3291, PG II <br />TY15 - 20 laal Tub (Chemo) (2.7 cu ft) <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 />LIN 3291, PG II <br />Cu Ft. <br />Pharmaceutical haste <br />Cu Ft, <br />tely TOTA 11. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fullffirnm1al <br />Cu Ft. <br />above by the proper shipping name, and are classified, packaged, marked and laed, d <br />respects in proper condition for transport according to applicable international and regul s.'Pn <br />4ibed <br />d/Typed Name <br />NSPORTER 1 ADDRESS: <br />Date `� <br />Phone #: <br />(559) 275 - 0994 <br />Q <br />W <br />Stericycle, InC. <br />Applicable Permit Numbers: <br />cc <br />4235 hest Swift Ave. <br />❑ $ h Shipment <br />2 0. <br />Fresno 3722 <br />�%' <br />a Z <br />TRANSPORTE IF "ell of I waste as dosed ove. <br />hh <br />~ <br />7 <br />PrinUType Name ignature <br />S. INTERMEDIATE HA DL R 2 / TRANSPORTER 2 ADDRESS: <br />Date / <br />Phone A: <br />Cr r, <br />Applicable Permit Numbers: <br />Iwo <br />Q.M <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as descnbod above. <br />az_ <br />Pdnt(Type Name Signaturo <br />Date <br />n w <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />a <br />Applicable Permit Numbers: <br />w <br />raw <br />R20 <br />i <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />=w= <br />cc <br />PrinUType Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />ThMiened t000talners, CU Q to : North Sat! Lake, UT <br />} <br />F-+ <br />A. Designated Facility: 88. Alternate Facility: 8C. Attemate Facility: <br />INC <br />ea. Altemate Facility: <br />STERICYCLE INC <br />STERICYCLE INC STERICYCLE INC STERICYCLE <br />a <br />4135 W. SWIFT AVE 90 NORTH 1100 WEST 9053 NORRIS AVE. <br />2775 E 28TH STREET <br />LL � <br />FRESNO,CA 93722 NORTH SALT LA)e CIN, UT SUN VALLEY, CA 91352 <br />VERNON, CA 90023 <br />(559) 275 - 0994 (80 1) 938 - 1555 (818) 504 - 6937 <br />(323) 362 - 3000 <br />Z <br />TS31. TSIOST25 TSd4S122 Cass V Indner bw Petml # 91 <br />P-6, P-11 S <br />a <br />W <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to 6fcept untreated medical wastes and that I have <br />1- <br />received she above incite eli'wa to in accordance with the requirement outtinedin That auttiorizalion. <br />Tf� ��v �fZ Signature r 4L ✓ <br />Date ACT a 9 lam <br />Print/Type Name <br />i <br />000781. <br />ORIGINAL <br />�erer�rst't�_ne.ns.�rrta _ <br />