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MEDICAL WASTE TRACKING FORM NUMBER <br /> o.®o Stericycie' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1.800-424-9300 STANDARD MANIFEST 001.10.08•STO <br /> • ptolmi,gPeople.RedudnpRkk' Route #: 023 — CUSTOMER NO.211132 MDFROOJR2U <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:rCerri Grenx <br /> SATELITTL" 111I77,TSIS -- STOCKTON <br /> 590 E HARDI'NG WAY <br /> STOMM-N, CA 96204- 6110 <br /> (209) 774-6800 10/10/2017 <br /> CUSTOMER NumoER (5077750-042 GENERATOR'S REGISTRATION# <br /> 2A.DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C. NO.OF 2D. VOLUME <br /> UN3291 Regulated Medical Waste,n,o.s„ CONTAINERS <br /> 6.2,PGI TBOS 40 Gal Tub (Rio) (5.3 Cu €t) Cu Ft. <br /> UN3291 Regulated Medical Waste,n.o.s,, TB49 — 37 Gal Tub (BiO (4.9 Cu ft) <br /> 6.2. Cu Ft. <br /> im 6UN3291iI Regulated Medical Waste,n.o,s„ TB14 - 44 Gal +Tub(8i,o) (5.9 Cu 'Lt) ! <br /> h Cu Ft <br /> Q UN3291 Regulated Medical Waste,n,o,s„ T — BIQ TP1 — Pa } TY — C ema 20 tea T 0EWT} <br /> I= 6.2,PG11 Ou Ft. <br /> W UN3291 Regulated Metlical Waste,n,o,s„ W1831-(Bi.o)/rAP31®(Path)/WtC31m(Chemo)31 Gal Tub(4.14CUFT) <br /> Z 6,2,PGI) Cu Ft. <br /> 6 2.P9G11i Regulated Medical Waste,n,o.s., w843_(Bio)/Pw63_(path)J 3—(Chemo) Gal Tub(S.7CUFT) Cu Ft <br /> UN3291 Regulated Medical Waste,n.o.s„ KRB _ Biosystems Cardboard Box (4.2 cu ft) <br /> 6.2,PGI Cu Ft. <br /> 1!143291,Regulated Medical Waste,n,o,s„ <br /> 62,PGii Cu Ft. <br /> UN3291 Regulated Medical Waste,n.o.s„ <br /> 6.2,PGII Cu Ft. <br /> 3.Generator's Certification:11 hereby declare that the contents of this consignment are fully and accurately 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 re ti <br /> v IPrintedriypedName �iYr� Signature Date <br /> CTRANSPORTER i ADDRESS; Phone# (866)783-7422 <br /> �° StOtiC'yCle, Inc. EjThis is a Through shipment 0Applicable Permit Numbers. <br /> O 4135 V. Swift Ave Hauler Reg# 3400 <br /> a. Freano,CA 93722 <br /> a Z TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> R1 L.-�.�� <br /> Printriype Name Signature Date <br /> 6.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS* Phone#: <br /> sS Applicable Permit Numbers. <br /> 6c„ INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br /> F� Pdntltype Name Signature Date <br /> a.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#: <br /> g Applicable Permit Numbers: <br /> N�$ INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as descnbed above. <br /> x <br /> PnnVType Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> A.Dosignatod Facility: U ea.Alternate Facility: 8C.Alternate Facility: ®8D.Alternate Facility: <br /> :fit illa cle.Inc. Stedcycle,Inc. Sterlayale,inc. <br /> v <br /> <br /> <br /> <br /> TREATMENT PI rtlfy that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> I— received the aboo a nl d a"wastes in accordance with the requirement outlined In that authorization. <br /> 7PrIntiTyps Name Signature Date <br /> s <br /> UFF60 <br /> ®FiIaIfilAi.CU n la <br />