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e MEDICAL WASTE TRACKING FORM NUMBER <br />ag®6 JAI ei�IlCyCle' IWE,8F#VEJGACY_CO§TACT:CHEMTREC1.800.424-9300 STANDARD MANIFEST 001-1006•STD <br />protecting Peapia Redudng Rick.' CUSTOMER NO. 21132 M®' ROi7HNIV <br />1. Generator's Name Address and Telephone Number 11111111111111111111111111111111111111111111 <br />STOCKTON PERSONAL CARE CENTER <br />601 N CALII'ORNIA ST <br />STOCKTON, CA 95202- 2118 <br />(209) 466-8075 3/30/2016 <br />CUSTOMERNumsER 6038112-002 <br />2A. DESCRIPTION OF WASTG 2B. <br />UN3291Regulated Medical Waste, R.o.s., TBOS <br />6 2, PGII <br />UN3291 Regulated Medical Waste, n.o s., <br />6.2, PGII <br />® 6 2329iPGIRegulated Medical Waste, n.o s., <br />Q UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGI <br />W UN3291, Regulated Medical Waste, n.o.s., — <br />IZ 62,PGII <br />UN32911 Regulated Medical Waste, ri.o.s., <br />GENERATOR'S REGISTRATION # <br />CONTAINER TYPE <br />Tub (Bio) (5.3 cu ft) <br />C <br />asa.v=YZaeiu= esal:uc]va&U aux lex. <br />3. Generator's Certification:'? hereby declare that the contents of this consignment are fully and accurately I TOTALS <br />10- <br />described above by the proper shipping name, and are classilied, packaged, marked and labelled/placarded, and <br />are In all respects In proper Condition for transport according to applicable International and national governmental regulations" <br />/ <br />t t t" Cu Ft. <br />Printed%ped Name (%rn Signature a Jd ` <br />4.TRANSPORTER iAt i Rcycle� Inc. ® This is a Through Shipment Phone#: <br />"a <br />413S -V. Swift; Ave Appilbio erm t mbe <br />a �,au� ereg' 3400 <br />a Q <br />�U) <br />FrZ,CA 93722 <br />0. <br />a a <br />TRANSPORT R CERATION: ecelpt of medical waste as de i a ve <br />�V <br />h' <br />C <br />(% ,./!� <br />��A <br />Print/rype Name Signature <br />Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #. <br />Wl f5 <br />Applicable Permit Numbers: <br />id <br />z F9 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinVrype Name Signature <br />Date <br />r, <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. <br />Phone #: <br />a is <br />1w�1 <br />Applicable Permit Numbers• <br />V a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />zWs <br />Print/Type Name Signature <br />Date I <br />10 <br />A Dealia ted Facility: 88. Alternate Facility: 8C. Alternate Facility: L] 8D. Alternate Facility: <br />StUcycle, Inc. Sterlcycle, Inc. Stedcycle, IRC. <br />4136 W. Swltt Ave p 90 N. Foxboro Drive 1551 Shelton Drive <br />Fresno.CA 937!'_%E North Salt Lake, UT 84054 Hollister, CA 95023 <br />(866)783-7422(888)7M7422 (866)783-7422 <br />TSFOST22 MAR 3 ® 16 3A -448 -JA -36 TSfOST 83 <br />TREATMENT FACILITY, I ceftity th ave been authorized by the applicable state agency to accept untreated medical wastes and that i have <br />received the above Indicated wastes in accordance with the requirement outlined in that authorization <br />Pdntr ype Name Sig_najurg Date <br />ORIGINAL <br />