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® CUSTORER SERVICE:- MEDICAL-WASTE TRACKING iFORM NUMB[ <br /> 0 Stericycle' INCA' Thank Sou for chO0Sin8 Steric9cle -9300 STANDARD MANIFEST 001-10-06-STD <br /> • PI.W6.9 P.11..Reducing Risk: I 021132 <br /> 'ROOATTO <br /> - <br /> 'i.Generator's Name,Address and Telephone <br /> ATTN-. i "aF. <br /> STO Oc WA ONIMUny <br /> ! <br /> 21626 1 CALIFORNIA ST <br /> (20 466-2626 4/26/2013 <br /> CUSTOMER NUMBER 6039584-002 <br /> GENERATOR'S REGISTRATION# <br /> 2A.DESCRIPTION OF WASTE 2B• CONTAINERTYPE 2C. NO.OF 2D. VOLUME <br /> UN329t,Regulated Medical Waste,n.o.s., tAJ CONTAINERS <br /> T857EB,iaa) { � t3 <br /> 6.2,PGII <br /> Cu <br /> UN3291,Regulated Medical Waste,n.o.s., T549 _ 37 13141 Tub (Viol (4. C ft) <br /> 6.2,PGII <br /> Cu <br /> CC UN3291,Regulated Medical Waste,n.o.s., TH14 _ 44® Gal. ( A orb 1 . t1 <br /> 6.2,PGII' <br /> Cu <br /> CC UN3291 Regulated Medical Waste,n.o.s., f3 3- (111 A} (2.7 cu It) <br /> ) <br /> C 6.2,PGII Cu <br /> W UN3291;Regulated Medical Waste,n.o.s., xBS ,- &' .T <br /> 6.2,PGIIZO Uj Cu <br /> UN3291;Regulated Medical Waste,n.o.s., <br /> 6.2,PGII TY15 211 Qat. T (Chemo) (2.7 cu ft.) <br /> Cu <br /> UN3291`;Regulated Medical Waste,n.o.s., t <br /> 6.2,PGII "T 'I y I <br /> ;rr Cu <br /> UN3291;Regulated Medical Waste,n.o.s., <br /> 6.2,PGII <br /> Cu <br /> Phairmacieutical Wast* Cu <br /> 7 <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTi4Ls ® + cf / Cu <br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,ap5 <br /> are in all respects in proper condition for transport accorclog to applicable international and national governor tai gula l0 " <br /> Printedlryped Namur �lA; t''fe r 4911. t Date <br /> 4.TRANSPORTER 1 ADDRESS: I Phone�:55 )275-1-, <br /> W to 1 , Inc. ss a- throughSh dirt Applicable Permit Numbers. <br /> M 4135 t Swift. Ave. <br /> CCL l) � rto C 93722 <br /> CL Q TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br /> CC <br /> Print/Type Name t ';'4.Y. Signature Date <br /> 5.INTERMEDIATE HANDLER'2/TRANSPORTER 2 ADDRESS: Phone#: <br /> - <br /> -W q Q Applicable-Permit Numbers: <br /> 2QJ <br /> ZOC= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:-Receipt of medical waste as described above. <br /> a� <br /> E Print/Type Name Signature Date <br /> CO W 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#: <br /> o w Applicable,Permit Numbers: <br /> w <br /> 0-s a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> zUJI <br /> x <br /> x— Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Triullsfilmd - `.:' Lake UT <br /> } =2 $A.Designated Facility: Q"6B.Alternate Facility: ❑8G:Aiteniate Facility: E]6D Alternate Facility: <br /> :3 2 Inc_A 1 Ir n SWboo IncA I -Atftdave <br /> Q 4135 Ift RVM 90 NORTH I 100 WWT I e as C 2775 E 2M STREET <br /> LL FRESN0,CA 0722 NORTH SALT LAKE CJTY,LIT 77 VERNON,CA WW3 <br /> a (6559)275 A 1121 (ac - 1655Z 7E ' { !MW-2M <br /> W3A-448-JA-36 Tswrsmns TSMT-26 <br /> HW TREATMENT FACILITY: I certify that I have been authorized by the applicable state,agency to accept untreated medical wastes and that I have <br /> received the above indicatedwastesin accordance with the requirement outlined in at authorization. <br /> i <br /> PrinUType Name Signature Date <br />