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MEDICAL WASTE TRACKING FORM NUMBER <br />i• <br />• • • Stericycle' IN CASE <br />•.• �..��,..�.-VErd � ENCYT� TA&�C i- 1 $�3UU STANDARD MANIFEST 001.10.06•STO' <br />Route •- <br />�.� <br />MDEROD93KZ <br />rptRwrr<sr6M0Id alilla-2¢10 ORIGINAL <br />1. Generator's Name, Address and Telephone Number <br />ATTN: til>_idy Jasperson ji <br />tj <br />SODEXO LAUNDRY SERVICES, INC <br />- 7679 S LUNG STREET <br />STUCKTUN, GA 95206 <br />(-209) 982-4955 <br />3/5/2010 <br />6048671-002' <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />REGULATED MEDICAL WASTE, n.0.s.,6.2, <br />TE57 - 90 Gal Tub (Bio) (12 cu ft) <br />CONTAINERS <br />UN 3291, PG II <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.c.s.,6.2, <br />T849 - 31 tial Tub (Bio) (4.9 CLI t:t) <br />UN 3291, PG II <br />Cu Ft. <br />CC <br />REGULATED MEDICAL WASTE, n.o.s..6.2, <br />TB14 - 44 Gal Tub (Bio) {. . 9 CU it) <br />Q <br />UN 3291, PG II <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 />T815-20 Oal TU Pa cu <br />— <br />W <br />UN 3291, PG It <br />Cu Ft. <br />(7 <br />REGULATED MEDICAL WASTE,n.o.s.,6.2, <br />TY15 - 20 Gel Tub (Chemo) (2.7 cu ft) <br />UN 3291, PG II <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.os.,-7�1/h{/� <br />UN 3291, PG II <br />"'(0-41 <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />UN 3291. PG II <br />Cu Ft. <br />Pharmaceutical Waste <br />Cu Ft. <br />3. Generator's Certification: 'I hereby declare that the contents of this consignment are fully and accurately TOTALS lli� <br />Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled placarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental reqlafions" <br />e <br />Printedfryped Name Signature <br />4. TRANSPORTER tb DRESS: <br />ericycle, Inc. <br />D111 1% at <br />ne #: t) — <br />W <br />W <br />� <br />4135 West Swift Ave. <br />Applicable Permit Numbers: <br />is a Through Shipment <br />a <br />Ca 93722This <br />Q <br />Ze3, <br />TRANSPORTE�CATIQ&4of i m a ed above. <br />PrinVType N Si na <br />Date <br />S. IN—TERIVIEDIATElf HANDLER 21 TRANSPORTER 2 DDRESS: <br />Phone #: <br />Applicable Permit Numbers: <br />are ¢ <br />gWa <br />LU <br />i <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone k: <br />CC a r <br />Vw� <br />Applicable Permit Numbers' <br />ya a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />za�x <br />�— <br />Print/Type Name Signature <br />Date <br />7. DISCREP Y INDICATION <br />P'contalners, <br />Transle CU R to - Noah Salt Lake, UT <br />SA. Designated FacIll89. Alternate Facility: E) 8C. Alternate Facility: <br />STERICYCLF lNC STERICYCLE INC STERICYCLE INC <br />E] 8D. Altemate Facility: <br />STERICYCLE INC <br />4135 W. SWIFT AVE 90 NORTH 1100 WEST 9053 NORRIS AVE. <br />2775 E 216TH STREET <br />a <br />FRESNO.CA 93722 NORTH SALT LAKE CITY, UT SUN VALLEY, CA 91352 <br />VERNON. CA 90023 <br />z(559) <br />275 - 0994 (80 1) 936 - 1555 (818) 504 - 6937 <br />(323) 362 - 3000 <br />TS31,TS/OST25 TS/OST 22 Classy Indnelatlon Pe1Tr11t#91- <br />2 P-6, P-! t5 <br />W <br />Q <br />I <br />W <br />TREATMENT FACILITY: I c qq d by the applicable state agency to accept untreated medical wastes and that I have <br />indicateb�tcoCea� outlined in that authorization. <br />Fes— <br />received the above requirement <br />Print/Type Name Signature <br />MAR to 211.1111.11 <br />Date <br />00082.9 3...a t)bIIIIII- <br />rptRwrr<sr6M0Id alilla-2¢10 ORIGINAL <br />