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• C p MEDICAL WASTE TRACKING FORM NUMBER <br />00"' <br />` ter is`�cle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -SM• Pi01*Cft?•0Pl0.8eduQn2Nsk' Routh ##: 134 — 9 CUSTOMER NO. 21132 MLiFROOHOI P <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />STOCKTON PERSONAL CARE CENTER <br />601 14 CALIFORNIA ST <br />STOCKTON, CA 95202- 2118 <br />(209) 466-8075 <br />CUSTOMER NUMBER 6038112-002 GENERATOR'S REGISTRATION # <br />4/6/2016 <br />2A. DESCRIPTION OF WASTE 25• CONTAINER TYPE 2C. NO. OF 2D. VOLUME <br />623291, Regulated Medical Waste, n.o.s, CONTAINERS <br />TB05 — 40 Gal Tub (Bio) (5.3 cu ft) <br />62, PGII Cu Ft <br />62. PGI Regulated Medical Waste, n.o.s., TB49 - 37 Gal Tub (Bio) (4.9 cu ft) r�. Cu Ft <br />p <br />6 23PGII Regulated Medical Waste, n.o s., <br />TB14 - 44 Gal Tub (Bio) (5.9 Cu ft) <br />W <br />Applicable Permit Numbers <br />Q <br />6N3291 Regulated Medical Waste, n.o.s., <br />PGII <br />TB21- (BIO) /T1?i5- (Path) /TYIS— (Chemo) 20 tial Tub (2.7CUt: <br />Lr <br />6.2, <br />UJ <br />W <br />UN3291, Regulated Medical Wast', n.o s., <br />6 2, PGII <br />UB31- (Bio) /WR31- (Path) /WC31- (Chemo) 31 Gal Tub (4.14CL <br />ccLj <br />6.2 3PGI� Regulated Medical Waste, n o s, <br />WB43- (Bio) /PW43— (Path) /CWd 3- (Chemo) Gal Tub (5.7CUFT) <br />62.PGilRegulated Medical Waste, n.os, <br />KRB - Biosystems Cardboard Box (4.2 cu ft) <br />xQQ <br />2�iq <br />UN3291, Regulated Medical Waste, nos., <br />Applicable Permit Numbers* <br />6.2, PGII <br />UN3291, Regulated Medical Waste. n.o.s.. <br />3. Generator's Certification: 01 hereby declare that the contents of this consignment are fully and accurately I TOTALS 01,- <br />described <br />1►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( <br />according to applicable International and national governmental regulati"ons" <br />Printed/Typed Name G, tA/ l t dow Signature 6 _1/ <br />/ q.7 Cu Ft <br />[r�A71199- <br />cc <br />4.TRANSPORTER 1 ADDRESS: I <br />Stericyale, Inc. ® This is a Through Shipment <br />Phone #: (866) 783-7422 <br />W <br />Applicable Permit Numbers <br />a o <br />4135 W. Swift Ave <br />mauler Reg# 3400 <br />no. <br />Fresno,CA 93722 <br />a a <br />TRANSPORTER CERTIFICATION: Receipt of medial waste as described above. <br />ccLj <br />Print/type Name /4'A4q7®- <br />L- L7A-z 6' Signature <br />Date <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone # <br />xQQ <br />2�iq <br />Applicable Permit Numbers* <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/lype, Name Signature <br />Date <br />M <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. <br />Phone #: <br />a <br />Applicable Permit Numbers, <br />M <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />x <br />Print/Type Name Signature <br />Date <br />1�=t <br />-I g <br />q. <br />LU <br />n <br />W <br />it <br />T. DISCREPANCY INDICATION <br />Designated Facility: Lj 8e. Alternate Facility: Lj 8C. Alternate Facility ❑ 8D. Alternate Facility: <br />Sterlcycle, Inc, 000 Stericycle, Inc. Stedcycie. Inc. <br />4135 W. Swl E 90 N. Foy bora Drt" 1551 Shelton Dfire <br />Fresno, t North Salt Lake, LIT 64054 Hollister, CA 95023 <br />rs22422©�SAas2 Sa22OS ��TSIT83 <br />A4 <br />TREATMENT FACILITY: 15'erIt91 <br />that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above fndicated wastes in accordance with the requirement outlined In that authorization. <br />PrinVfype Name Signature Date <br />Containers, cu tt to <br />ORIGINAL <br />