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e.-*.* Stericycle" Ftb%M Off �MJSWNCY CTWACT: CHEMTREC 1-800.424.930D <br />• PxtMial ft*Ple. Redating ?JsV CUSTOMER NO. 21132 <br />1. Generator's Natt i$ffess and Telephone Number <br />STOCKTON PERSONAL CARE CENTER <br />6011 N CALIFORNIA ST <br />STQCRTON, CA 95202- 2118 <br />6038112--002 <br />CUSTOMER NUMBER <br />2A. DESCRIPTION OF WASTE <br />UN3291' Regulated Medical Waste, <br />5.2, PGIE <br />UN3291, Regulatetl Medical Waste, <br />t= <br />UN3291, Regulated Medical Waste, <br />O <br />~4 <br />6.2, PGII <br />_ <br />UN3291, Regulated Medical Waste, <br />6.2, PGII <br />IN <br />Z <br />UN3291 Regulated Medical Waste, <br />62, PGI) <br />t11 <br />UN3291, Regulated Medical Waste, <br />Medical Waste, n.0.e., <br />Medical Waste, n.o s., <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STAN pAD"Vffi.D W.t 0.06 -STD <br />(209) 466-6075 <br />GENERATOR'S REGISTRATION # <br />28. CONTAINER TYP E <br />TBOS - 40 Gal Tub (81o) (5•3 cu ft) <br />I 3. Generator'$ Certification: "i hereby declare that the contents of this consignment are fully and accurately I TOTALS <br />described above by the proper shipping name, and are classified, packaged, marked and labelledtplacarded, and <br />are in all respects in proper condition for transport according to applicable intemational and national governmental regulations" <br />PrintedfljrpedName cy'"�R`^�" c�r Signature <br />4. TRANSPORTER 1 StWMyCle, Inc. This is a Through shipment <br />} 4135 W. Swift Ave <br />o FreanorCA 93722 <br />HCL <br />IL a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Prfnt/Type Name +�-r L/�• Signature <br />5. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS' <br />N <br />N INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />PrinUType Name - — Signature <br />3/23/2016 <br />20. NO. OF 21). VOLUME <br />CONTAINERS <br />Cu F <br />i3 • Cu F <br />Cu F <br />Cu F <br />Cu F <br />Cu F <br />Cu F <br />Cu F <br />�7 Cu F <br />Y� { Cu F <br />t� <br />Phone #. <br />Ap i an"I& ' 13400 <br />Date <br />Phone # <br />Applicable Permit Numbers. <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: <br />Applicable Permit Numbers <br />a INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Z <br />o- PdnMpsName Signature Date <br />IN <br />7 <br />SDBTICYCI0. r1cty. <br />4136 We SWR A <br />gn <br />Fresno,CA 937 <br />(866)763.7422tai <br />TS/OST22 0'4" <br />a. Aftemate Facility: <br />walcycle,Inc. <br />90 N. Foxboro DrIn <br />North Salt Lake. UT 84054 <br />(866)763-7422 <br />3A -448 -JA -36 <br />8Cornate Faciffty: <br />kawde, Inc. <br />1651 sholton Dr" <br />Halilster, CA 95023 <br />(666)783-7422 <br />TS/03T 83 <br />80. Aftemate Facility: <br />Stericycle, Inc. <br />3140 N 7th StreetbV <br />Kansas City, KS 66115 <br />(066)788-7422 <br />TSJOST 26 <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 />recelved the above Indicated wastes in accordance with the requirement outlined h that authorization. <br />PrinttType Name sio®,ast� Date <br />