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MEDICAL WASTE TRACKING FORM NUMBER <br />O •®O Stericvcle" IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-4249300 STANDARD MANIFEST 001.10.06 -STD <br />• ® P,oteoft People RnKln Me <br />Route #: 734 — 8 CUSTOMER NO. 21132 NIDFRt?OHLPS <br />re�''It <br />QC <br />W <br />Z <br />i JI <br />1. Generator's Name, Address and Telephone Number <br />ATTN <br />STOCKTON PERSONAL CARE CENTER <br />601 N CALIFORNIA ST <br />STOCKTON, CA 95202— 21.18 <br />(209) 466-8075 <br />CusmmERNUMB$R 6039112-002 GENERATowsREGISTRA'noN# <br />2A. DESCRIPTION OF WASTE 2B• CONTAINERTYPE <br />UN3291 R ut to At 1 W <br />3/16/2016 <br />2C. NO. OF 2D. VOLUME <br />CONTAINERS <br />6.2, PGfi a q Me ca W. n.os., <br />TB05 - 40 Gal Tub (Bio' (5.3 cu ft) <br />Cu Ft <br />UN362. PGII 91 Regulated Medical Waste, n.o.s„ <br />TB49 - 37 Gal Tub (Bio) (4.9 cu ft) <br />Cu Ft. <br />U 2. PGI Regulated Medical Waste, n.os., <br />8.2, PGlf <br />TB14 - 44 Gal Tub (Bio) (5.9 cu ft) <br />Cu FL <br />UN32911 Regulated Medical Waste, n.o.s., <br />T82J.- (1330) /TP15- (Path) /TY15- (Chemo) 20 Coal Tait (2.7CUFT) <br />I sU23PPGI fteQOlateG Medical Waste, n.o.s.,I NO3,L-- (Hfo) /WP31- (Path) /WC31- (Chemo) 31 Gal Tub (4.14CUF'T� <br />i <br />o, -Fa .,tea-, — --- . ""' 1B93- (Bio) /PN43- (Path) /Cfd43- (Chemo) tial Tub (5.7CUFT) Cu Ft. <br />1123291 Regulated Medical Waste, n.os., <br />62, PGMo— - Biosystems Cardboard Box (4.2 cu ft) II sY Cu Ft <br />Medical Waste, <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS <br />110 <br />described above by the proper sh)pping name, and are classilled, packaged, marked and labelledrplacarded, and <br />are In all respects in proper condition for transport according to applicable international and national governmental regulations" <br />Printe ped Name ��a4 ex k il e, % ✓ & S'� Sianature <br />4. TRANSPORTER 1 ADDRESS: <br />Stericycle, Inc. <br />4135 W. Swift Ave <br />a. Eresno,CA 93722 <br />a g TRANSPORTER CERTIFICATION: Receipt of <br />No <br />PrinVe 0 <br />This is a Through shipment <br />waste as described above <br />Date 3 / <br />Phone#: (866)783-7422 <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />Date -1-1 <br />V- f CJ <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS.- ^-- \ Phone 11 <br />I'Mq ����/) Applicable Permit Numbers: <br />Rig INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/lype Name Signature Date <br />M 5. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone # <br />Applicable Permit Numbers <br />w <br />s Z' INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />z� <br />0- Print/Type Name Signature Date <br />IF <br />11!R <br />LU <br />!F <br />Y <br />7. DISCREPANCY INDICATION <br />8A. Designated Facility: .�L <br />Stericycie, Inc. v.EO�` <br />4185 W. SWIR A0P�' <br />Fresno,GA 9022 <br />(868)783-7422�� <br />TS/OST22 ` 01 <br />8B. Alternate Facility: <br />Stericycle, Inc. <br />90 N. Foxboro DM <br />North Salt Lake, Lrf" 84054 <br />(866)783-7422 <br />3A -448 -JA -36 <br />8C. Alternate Facility: <br />Stericycle, Inc. <br />1561 Shatton Drive <br />Hollister, CA 95023 <br />(866)783-7422 <br />TS/OST 83 <br />8D. Alternate Facility: <br />Stericycle, Inc. <br />3140 N 7th Streettry <br />Kansas CiLY, KS 66115 <br />(866)783-7422 <br />TSfOS'i +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 />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />PdnMPG Name Signature <br />containers, cu ft to : North Safi Lake, UP <br />Date <br />