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To:+1-2094688392 Page 2 of 14 2010-10-19 15:17:34 GMT-06:00 18003811139 From:SQ CS Team 2
<br /> MEDICAL WASTETRACKING FORM NUMBER
<br /> 00 Steri le' IN CASE OF EM ENCY C ACT:CNEMTREC 1-800.424-9300 STANDARD MANIFEST 001-1046-STD
<br /> a-• ,.,�,�„ �.: Route #; - MDFR®09V9N
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ATTN.- Bobbie !! 1
<br /> ECO-STO=TON PROF CEWM
<br /> 6529 INGLEDOOD AVE STE B3
<br /> STociic PON, CA 95207
<br /> (209) 476-3886 9/7/201(
<br /> CUSTOMER NUMBER 6038268-003 GENEAArows REGISTRATION
<br /> 2A,DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO.OF 2D. VOLUME
<br /> UN3291,Regulated Medical Waste.n.o.s., TH57 - 90 tial Tub (Bio' (12 cu It) CONTAINERS
<br /> 6.2,PGII Cu Ft,
<br /> UN3291,Regulated Medical Waste,n.o.s., TB49 - 31 Gal Tub (81.0 (4.9 Cu It)
<br /> 6.2.PGII Cu Ft,
<br /> Q[ UN3291,Regulated MedW Waste,n.o.s., T014 — o Cu
<br /> ® 6.2,PGII Cu FI.
<br /> UN3291,Regulated Medical Waste,n.o.
<br /> f= 6.2.PGII Ft.
<br /> W UN3291,Regulated Medical Waste,n.o.s., TB1S — 20 Gal Tub (Pach) (2.7 cu fQ
<br /> IZ 6.2.PGII Cu Ft.
<br /> UN3291,Regulated Medical Waste,n,o.e., TY1S — 20 Gal Tub (Chemo) (2.7 cu ft)
<br /> 6.2,PGII
<br /> Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2.PGII Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII Cu Ft.
<br /> Pharmaceutical wast®
<br /> Cu F.
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are Fully and accurately TOTALS /' ,, F1
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and
<br /> are in all respects in proper con '' n for transport acro g to applicable International and national govemme gu s'
<br /> Prints ed Name SI nature Date •
<br /> 4.TRANSPORTER 1 ADDRESS. Phone 0: —
<br /> cc Steracycle, Inc.
<br /> 4135 t Swift Ave. Applicable Permit Numbers:
<br /> 0 Th Le is a Through Shipment
<br /> EL Fresno,Ca 93722
<br /> a TRANSPORTER C Fl ION: of medical waste as de •
<br /> Print/Type Name Signature Date
<br /> S.INTERMEDIATE AMLER 2/TRANSPORTER 2 ADDRESS: Phone 0:
<br /> Ua1
<br /> Applicable Permit Numbers:
<br /> UM J
<br /> SM
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as descried above.
<br /> Print!Sipe Name Signature Date
<br /> a, 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 0:
<br /> a a Applicable Permit Numbers:
<br /> w
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Z s
<br /> — Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> ThMfWMd catalnem, ei ft to: Nofth Sall Lake,UT
<br /> $A.Designated Facility: aa.Alternate Facility: 015C.Aaemate Facility: a®.Alternate Facility:
<br /> Sbuicycle Inc-Autu*m a Ino-Inclner0on Stwkyde Inc-Autockw StairlcVcle Inc-Autoclave
<br /> Q 4135 W.SWIFT AVE 90 NORTH 1100 1345 Drive C 2775E STREET
<br /> . PRESNO,CA 93722 N SALT C CA TTVERNON.CA 80023
<br /> (559)275-am (601)936- 1555 (510)562-1781 (323) -3000
<br /> TS31,TSIOSIM TSIOSIM Mimi V Indneratlon Peffrilt 91 P-5,P-1 IS
<br /> w
<br /> TREATMENT FACILITY: 1 Gertity that 1 have been authorized by the applicable state agen accept untreated medical wastes and that I have
<br /> F received the abave'lpdic3!"ed es in accordance with the requirement ou in tha rization.
<br /> Print/Type Name;'. A E G' /Q signature `�" - oats SEP 0;8 2010
<br /> 17
<br /> 00067
<br /> 03 sep2ot® ORIGINAL
<br />
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