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To:+1-2094688392 Page 3 of 14 2010-10-19 15:17:34 GMT-06:00 18003811139 From:SO CS Team 2 <br /> -- <br /> MEDICAL WASTE TRACKING FORM NUMBER <br /> ®®00 Stericycle' IN CASE OF EMERGENCY CONTACT,CHEMTREC 1-800-4244300 STANDARD MANIFEST 001-$O-WSTD <br /> Route : 800 - 7 MDFRO09RII <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN: Bobbie III III 111111111 III I I III <br /> ECO-STOCRTON PROF CENTER <br /> 6529 IWGLEROOD AVE STE B3 <br /> STOCKTOV, CA 95207 <br /> (209) 478-3886 8/10/201( <br /> CUSTOMER NUMBER 6038268-003 GENERATows REGisTRAnoNr <br /> 2A.DESCRIPTION OFWASTE 28. CONTAINERTYPE 2C. NO.OF 2D. VOLUME <br /> UN3291,Regulated Medical Waste,n.o.s., CONTAINERS <br /> 6.2,PGII T957 - 90 Gal Tub (Bio) (12 Cu tt) Cu FI. <br /> UN3291 PGI Regulated Medical Waste.n.o.s.. <br /> 6.2.2,PGI T349 - 37 cal Tub (Bio) (4.9 Cu ft) <br /> Cu Ft. <br /> p 62, PG1i Regulated Medical Waste,n.as.' TS14 - 44 Gal Tub(Bio) (S.9 Cu tt) <br /> Cu Ft. <br /> ta Q 623 PGII Cy <br /> Medical Waste,n.o.s., T921 - 20 Gal Tub(Bio) (2.7 Cu tt) Cu FL <br /> W UN3291,Regulated Medical Waste,n.o.s., TS15 - 20 Gal Tub (Path) (2.7 cu ft) <br /> ZW 6.2,PGII Cu FL <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2,PGII TY15 - 20 Gal Tub (chemo) (2.7 cu ft) 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 /> F. <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS Cu Ft. <br /> described above by the proper shipping name,and are classed,packaged,marked and labelied/piaoarded,and <br /> are In <br /> all respects in proper ndiUo coir t according to applicable international and national gov nme u s <br /> ! IPrinted/Typed Name Signature JA. s Date <br /> 4.TRANSPORTER 1 ADDRE : Phone a: (559) 275 — 0 <br /> w Steracycle, Inc. Applicable Permit Numbers: <br /> r�E <br /> R 4135 t Swift Ave.Fresno,Ca 93722 is is a Through Shipment <br /> N <br /> a Q TRANSPO R CERTIFICATION:Receipt of medical waste as de bad above. <br /> � L y <br /> PrinVType Name Signature Dat <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone 9: <br /> n <br /> � <br /> Applicable Permit Numbers: <br /> w� <br /> �o <br /> y <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as descdbed above. <br /> Printfrype Name Signature Date <br /> .:, 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone <br /> q: <br /> c Ic Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> a <br /> Print/Type Name Signature Gate <br /> 7.DISCREPANCY INDICATION <br /> Trandtsrtsd cantaine ei R to : North Sall Lake,UT <br /> 8A.Designated Facility: 813.Alternate Facility: ®8C.Aftemato Facility: 80.Alternate Facility: <br /> Steticyde Inc-Autodeve Ste�ricyde Ino,Indne Steri yde Inc-Autod�se Stericyde Inc-Autot ie <br /> 4135 W.SWIFT AVE 90 NORTH 1100 T 1345 Dool4lfe Drive Ste C 2776 E 213TH STREET <br /> L FRESNO,CA 93722 NORM SALT LAKE CITY.UT San Leandro.CA 94577 VERNON.CA MM <br /> if <br /> (559)275-OM (801) - 1555 (510)50- 1781 (323)362-3 <br /> w TS31.T5/OST26 TS/OST22 ClassV Irwilnendlon PerrnW 91 02 P-S,P-116 <br /> W TREATMENT FACILITY:i certify that 1 have been authorized by the applicable state agencyto accept untreated medical wastes and that I have <br /> H received the above indica w s in accordance with the requirement outlo&in that a" 'rization. AUG 1 0 2010 <br /> r' <br /> Prinf/Type Namer Signature Date <br /> 000276 <br /> ORIGINAL <br />