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-�MEDICAL WASTE TRACKING FORM NUMBER <br />StericyCle' CASE OF EMERGENCY CONTACT: CMEMTREC 1-800.234 005 <br />STANDARD MANIFEST 001 -10 -08 -STD <br />• IrvOKtbp P . MArb9 Affil: <br />Route #: 301 - 14 HnFR00RKC,P <br />ORIGINAL <br />1. Generator's Name, Address and Telephone Number <br />ATTN: Judy Jasperson fllli�lillllll (illlll�l�i�lliilliil <br />I pill I I III <br />SODEXO LAUKEIRY SERVICES, INC <br />7679 S LONGE STREET <br />STOCKTON, CA 95206 <br />209 982-4955 <br />10/23/2009 <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION 0 <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />REGULATED MEDICAL WASTE, n.os..62, <br />CONTAINERS <br />UN 3291, PG II <br />TB57 - 90 Gal Tub (Bio) (12 cu ft) <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.o.s..6.2, <br />UN 3291, PG II <br />TB49 - 37 Gal Tub (Bio) (4.9 Cu tt) <br />Cu Ft. <br />([ <br />REGULATED MEDICAL WASTE. n.o.s..6.2. <br />UN 3291, PG II <br />T014 - 44 Gal Tu(5.9 Cu tt) <br />3 <br />17b(DiO) <br />p <br />Ce Fl. <br />Q <br />REGULATED MEDICAL WASTE, n.o.s.,62, <br />TB21 - 20 Gal Tub(Bio) (2,7 cu ft) <br />Cr <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 />TB15 - 20 Gal Tub (Path) (Z.7 cu Lt) <br />Cu Fc. <br />L <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />UN 3291, PG tl <br />rY15 - 20 Gal 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 .6 2, <br />UN 3291, PG II <br />Cu Ft, <br />Cu Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 100, <br />3 1 7. 7 CL Fc <br />described above by the propej shipping name, dare classified, packaged, marked and labellediplacarded, and <br />are in all respects in proper dition or tran rt axording to licable international and national govern nt a ions' <br />Iv <br />I A `l Printed/Typed Name ( Signature <br />4. TRANSPORTER 1 ADDR <br />Lo Z3 kef <br />Phone a: (559) 275 - 0994 <br />cc <br />} <br />Stericycle, Inc. <br />Applicable Permit Numbers: <br />2 <br />o <br />4135 West Swift Ave_ <br />[] This is Throu Shipment <br />m <br />rr N <br />Fresno, Ca 93722 <br />a a <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />¢ <br />~ <br />n <br />-Rel. <br />r Za <br />Print(Type Name ,/ Y i f Cl�)Yd. Signature <br />Date O I <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />r <br />i <br />Applicable Permit Numbers: <br />E�� <br />C) D <br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Z <br />a_ <br />Print/Type Name Signature Date <br />w <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone a: <br />w a ¢ <br />Applicable Permit Numbers <br />o a i <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />A� <br />—Print/Type <br />Name Signature Date <br />7. DISCREPANCY INDICATION <br />Transferred containers eu R to , North Sah Lake, UT <br />y � <br />SA- Designated Facility: 8B- Alternate Facility: Ej 8C. Alternate Facility: E] 8D. Alternate Facility: <br />J <br />STERICYCLE INC STERICYCLE INC STERICYCLE INC <br />STERICYCLE INC <br />v <br />I <br />4135 W. SWIFT AVE 90 NORTH 1100 WEST 9053 NORRIS AVE. <br />2775 E 28TH STREET <br />I <br />FRESNO,CA 93722 NORTH SALT LAKE CITY. UT SUN VALLEY. CA 91352 <br />VERNON. CA 90023 <br />(559) 275 - 09% (80 1) 936 - 1555 (S IS) 504 - 6937 <br />(323) 362 - 3000 <br />LU <br />TS31, TSIOST25 TSIOST22 Gass V Indrteradon Perry W 91 <br />2 P-6, P-115 <br />4 <br />W <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable stat agenc t cept untreated medical <br />wastes and that I have <br />� <br />received the above indic wa a in accordance with the requirement o n that ation. <br />�i4� OCT 2 3 20(19 <br />Print/Type Name Signature <br />Date <br />U <br />ORIGINAL <br />