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MEDICAL WASTE TRACKING FORM NUMBER <br />964 Stericycle' ---QASE OF EMERGENCY CO T: CH TREC 1-800-234-045 STANDARD MANIFEST 001-10.06•STD <br />r... ft -O --,e,. Route �: - � MDFRO08JHQ <br />rptlteMw605'taa 14-01-2009 ORIGINAL <br />1. Generator's Name, Address and Telephone Number <br />ATTN. Judy Jaspereon <br />SODEXO LAUNDRY SERVICES, INC <br />7679 S LONGE STREET <br />STCC,'K'MN, CA 95206 <br />(209) 9B2-4955 <br />10/16/2009 <br />6048671-002 <br />CUSTOMER NUMBER GENERATOR'S REGISTRAnOH e <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />21D. VOLUME <br />REGULATED MEDICAL WASTE, n.o.s.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, n.o.s.,6.2. <br />TH - 37 Ga Bio cu <br />UN 3291, PG II <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />TS14 - 44 Gal Tub(Hio)Cu <br />n <br />�' C7 <br />Q <br />UN 3291, PG II <br />` <br />Cu Ft. <br />Q <br />REGULATED MEDICAL WASTE, n.o.s.,6.2. <br />TB2t 20 Gat Tahcll!1110 (2.7 cut ft) <br />Fx <br />UN 3291, PG II <br />Cu Ft. <br />W <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />THIS -20 Gal T Pd cu <br />W <br />UN 3291, PG II <br />Cu Ft. <br />Z5 <br />REGULATED MEDICAL WASTE, re.s.,6.2. <br />TY15 - 20 Gal Tub (chemo) (2 - 7 cu ft) <br />UN 3291, PG II <br />Cu Ft. <br />REGULATED MEDICAL WASTE, ne.s.,6.2. <br />UN 3291, PG 11 <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.os.,6.2, <br />UN 3291. PG II <br />Cu Ft. <br />Pharmaceutical fiesta <br />Cu Ft. <br />3. Generator's Certification: `I hereby declare that the contents of this consignment are fully and accurately TOTALS 10- <br />2 Ir Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />in all respects in proper condition for transport according to applicable international and national governmental ulations" <br />Tare <br />(/ T4 <br />I <br />f Printedlryped Name ` Signature <br />Date <br />w <br />4. TRANSPORTER <br />�terlCyCle, Inc. <br />Phone #: <br />9135 West Swift Ave. <br />Applicable Permit Numbers: <br />C]This a Th ough Shipment <br />a <br />Fregno,Ca 93722 <br />_y <br />a Q <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />CC <br />~ <br />V, ct/►'�"4, <br />to/i�oA <br />Print/Type Name Signature <br />Date <br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Phone a: <br />N <br />g1x <br />Applicable Permit Numbers: <br />ow <br />goo <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt <br />Z <br />of medical waste as described above. <br />PrinUType Name Signature <br />Date <br />6_ INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone k: <br />o u+ <br />Applicable Permit Numbers: <br />N a i <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />z�x <br />r- <br />Print/Type Name Signature <br />Date <br />7- DISCREPANCY INDICATION <br />Transferred containers, cu R to : North Salt Lake, UT <br />8A. Designated Facility; 88. Alternate Facility: E] 8C. Alternate Facility: El 8D. Alternate Facility: <br />STERICYCLE INC STERICYCLE INC STERICYCLE INC <br />STERICYCLE INC <br />v <br />4135 W. SVi AVE 90 NORTH 1100 WEST 9053 NORRIS AVE. <br />2775 E 26TH STREET <br />Q <br />LL <br />FRESNO,CA 93722 NORTH SALT LAKE CITY, UT SUN VALLEY, CA 91352 <br />VERNON. CA 90023 <br />@ <br />(559) 275 - 0994 (801) 936 - 1555 (8 18) 504 - 6937 <br />(323) 362 - 3000 <br />is <br />UjQ <br />TS31. TS/OST25 TSdOST22 Class V Iraidnerdon PermlW 91 <br />P-6, P-115 <br />U.JF a <br />TREATMENT FACILITY: I Certify that I have been authorized by the applicable s to age accept untreated medical <br />wastes and that I have <br />e <br />received the above indicate as in accordance with the requirement in th ation. <br />OCT 18 2009 <br />PrinUType Name _Signature <br />Date <br />000149 <br />rptlteMw605'taa 14-01-2009 ORIGINAL <br />