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Adh
<br />---- NUMBER
<br />• y MEDICAL WASTE TRACKING FORM NU
<br />®p Ste) icicle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.424-9300 STANDARD MANIFEST 001-10.06 STD
<br />• P.Ucf&, ft"14. Quft RW Route 0: 126 -- 1 CUSTOMER NO. 21132 l:'D ROOHOflR
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN-.
<br />STOCKTON PERSONAL CARE CENTER
<br />601 ?d CALIFORNIA ST
<br />STOOCKTON, CA 95202-- 2118
<br />(209) 466-8075
<br />4/1/2016
<br />2C. NO. OF 2D. VOLUME
<br />CONTAINERS
<br />Cu FL
<br />Cu Ft
<br />I n!) 1131111Reguiated Medfcai Waste, n.o.s.,1 P 'IA �� �� ,1 A q < J . I 1 I
<br />Medical Waste, n.o
<br />3. Generator's Certification:'I hereby declare that the contents of this consignment are fully and accurately I T®Ti4LSr 0,1 ' Cu Ft
<br />described above by the proper shipping name, and are classified, packaged, marked and labelde,V,Iacared, and
<br />espects in proper condition for transport according to applicable international and narnme�egul
<br />P Ied/Typed Name
<br />4.T SPO ER 1 ADDRESS: Phone#: (866) 793_7422
<br />w Stericycle, Incl. ® This is a Through Shipment Applicable Permit Numbers:
<br />Q 4135 W. Swift Ave 1lauler Reg# 3400
<br />,2 It.
<br />FresnarCA 93722
<br />a q TRANSPORTER CERTIFIC O : Receipt of medical waste as descricc
<br />b
<br />Print/lypa Name Signature Date
<br />5. INTERMEDIATE H LER Jr ANSPORTER 2 ADDRESS: Phone #:
<br />5 cc Applicable Permit Numbers:
<br />�z INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />F s PdnMpe Name Signature Date
<br />B. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
<br />.95 Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Prinlllype Nams Signature Date
<br />7. DISCREPANCY INDICATION
<br />} D 8A. Designated Facility: 86. Alternate Facility: 8C. Alternate Facility. ® 8D. Altomate Facility:
<br />-► Stericycle, Inc. Stericycle, Inc. Stedcycle, Inc.
<br />a 4135 W. SW* Ave 90 N. Foxboro Drive 1651 Shelton Drive
<br />w FresnD,CA 93722 North Salt Lake, UT 84054 Hollister, CA 95023
<br />Z (866)783-7422 (866)7M7422 (666)783-7422
<br />LuffTS/OST22 3A -448 -JA -36 TS/OST 83
<br />a
<br />I
<br />! TREATMENT FACILITY: I certify that i have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />h received the above indicated wastes In accordance with the requirement outlined in that authorization.
<br />PdnMpe Name Signature Date
<br />m
<br />Transferred containers, CU ft to
<br />c�
<br />,o
<br />ORIGINAL_
<br />CUSTOMER NumnEn 603811.2-002
<br />GENERATOR'$ REGISTRATION#
<br />2A. DESCRIPTION OFWA%TE
<br />2a• CONTAINERTYPE
<br />6 2, PGI Regulated Modlral Waste, n.o.s.,
<br />TB05 — 40 tial Tub (Rio) (5.3 cu ft)
<br />8.23291 Regulated Medical Waste, n.o.s.,
<br />62, PGI)
<br />TB4 9 — 37 Gal Tub (Bio) (4.9 ru ft)
<br />O
<br />623PGI1 Regulated Medical Waste n.o.s.,
<br />TH14 - 44 Gal Tub(Bio) (5.9 cu ft)
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGli
<br />Ts21- (BIO) /TPIS- (path) /TY15- (Chemo) 20 'Gal Tub (2.7CU2
<br />Z
<br />Z
<br />8.23291, Regulated Medical Waste, n o.s.,
<br />82, PM
<br />WB 31— (Bio) /WP31— (path) /WC31— (Chemo)31 Gal Tub (4.14CL
<br />iLI
<br />Vr
<br />62, PI� Regulated Medical Waste, n.os ,
<br />ikiB43— (Bio) /PW43— (Path) /Ciat43— (Chemo) Gal Tub (5.7CUFT)
<br />UN3291, Regulated Medical Waste, n.0 s.,
<br />6.2, PGII
<br />I KRB — Biosystems Cardboard sox (4.2 cu £t)
<br />4/1/2016
<br />2C. NO. OF 2D. VOLUME
<br />CONTAINERS
<br />Cu FL
<br />Cu Ft
<br />I n!) 1131111Reguiated Medfcai Waste, n.o.s.,1 P 'IA �� �� ,1 A q < J . I 1 I
<br />Medical Waste, n.o
<br />3. Generator's Certification:'I hereby declare that the contents of this consignment are fully and accurately I T®Ti4LSr 0,1 ' Cu Ft
<br />described above by the proper shipping name, and are classified, packaged, marked and labelde,V,Iacared, and
<br />espects in proper condition for transport according to applicable international and narnme�egul
<br />P Ied/Typed Name
<br />4.T SPO ER 1 ADDRESS: Phone#: (866) 793_7422
<br />w Stericycle, Incl. ® This is a Through Shipment Applicable Permit Numbers:
<br />Q 4135 W. Swift Ave 1lauler Reg# 3400
<br />,2 It.
<br />FresnarCA 93722
<br />a q TRANSPORTER CERTIFIC O : Receipt of medical waste as descricc
<br />b
<br />Print/lypa Name Signature Date
<br />5. INTERMEDIATE H LER Jr ANSPORTER 2 ADDRESS: Phone #:
<br />5 cc Applicable Permit Numbers:
<br />�z INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />F s PdnMpe Name Signature Date
<br />B. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
<br />.95 Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Prinlllype Nams Signature Date
<br />7. DISCREPANCY INDICATION
<br />} D 8A. Designated Facility: 86. Alternate Facility: 8C. Alternate Facility. ® 8D. Altomate Facility:
<br />-► Stericycle, Inc. Stericycle, Inc. Stedcycle, Inc.
<br />a 4135 W. SW* Ave 90 N. Foxboro Drive 1651 Shelton Drive
<br />w FresnD,CA 93722 North Salt Lake, UT 84054 Hollister, CA 95023
<br />Z (866)783-7422 (866)7M7422 (666)783-7422
<br />LuffTS/OST22 3A -448 -JA -36 TS/OST 83
<br />a
<br />I
<br />! TREATMENT FACILITY: I certify that i have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />h received the above indicated wastes In accordance with the requirement outlined in that authorization.
<br />PdnMpe Name Signature Date
<br />m
<br />Transferred containers, CU ft to
<br />c�
<br />,o
<br />ORIGINAL_
<br />
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