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To:+1-2094688392 Page 4 of 14 2010-10-19 15:17:34 GMT-06:00 18003811139 From:SQ CS Team 2 <br /> ® MEDICAL WASTE TRACKING FORM NUMBER <br /> ® Sterirycl®' <br /> IN CASE OF EMERGENCY :CHEMTREC 1.800424-9300 STANDARD MANIFEST 001-10-049-SM4?.*.** <br /> • ft"*.`&Ch-9Bgute : 800 - 8 MDER009MYG <br /> 1.Generator's Name,Address and Telephone Number I I I I I 1 I I!I <br /> ATTN: Bobbie 1 <br /> ECO-STOCRTON PROF CENTER <br /> 6529 INGLEWOOD AVE STS B3 <br /> STOCKTON, CA 95207 <br /> 209) 478-3886 7/13/201( <br /> CUSTOMER NUMBER -003 GENERATDR'9 REGIMATiON e <br /> 2A.DESCRIPTION OF WASTE 29. CONTAINER TYPE 2C. NO.OF 20, VOLUME <br /> UN3291,Regulated Medical Waste,n.o.s., CONTAINERS <br /> 5.2,P611 THS1 - 90 Gal Tub (Bio) (12 cu ft) Cu Ft. <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2,PGu TH49 - 37 Gal Tub (Bio) (A.9 cu tt) Cu FL <br /> ® 6 N3291 Regulated <br /> Regulatdf Medical Waste,n.o.s., TB14 - 44 Gal Tub(Bic) (5.9 Cu tt) <br /> Cu Ft. <br /> 6 2322911,Regulated Medical Waste,n.o.s., TB21 - 20 Gal Tub(Hio) (2.7 cu tt) Cu Ft. <br /> W UN3291,Regulated Medical Waste,n.o.s., <br /> Z 6.2.PGII THIS - 20 Gal Tub (Path) (2.7 Cu tt) Cu Ft. <br /> LU <br /> UN3291,Regulated Medial Waste,n.c.s., <br /> 6.2,P611 7Y15 - 20 Gal Tub (Chem*) (2.7 cu ft) Cu Ft. <br /> UN3291,Regulated Medial Waste,n.o.s., <br /> 6.2,PGII Cu Ft. <br /> UN3291,Regulated Medical waste,n.o.s.. <br /> 6.2,PGII Cu FL <br /> Cu Ft. <br /> 3.Generator's CerNflcatkm:11 hereby declare that the contents of this consignment are fully and accurately TOTALS Cu Ft. <br /> described above by the proper shipping nacre,and are classified,padoged,marked and labelled/placarded,and <br /> are in all respects in proper ndition for transport according to applicable international and national gov rnmental regulations." <br /> IPrtnt ed Name of e- n signatu i— ate <br /> 4.TRANSPORTER I ADDRES • Phone b: (559) 275 - 0 <br /> Stericycle, Inc. Applicable Permit Numbers: <br /> FIC a 4135 West Swift Ave. VIA is is a Through Shipment <br /> Fresno,Ca 93722 <br /> a TRANSPORT IF ATION_ Receipt of medical waste as des rib ove. <br /> tz - <br /> ~ Print/Type Name Signature Date <br /> S.INTERMEDIATE HANDLER 2/ RANSPORTER 2 ADDRESS: Phone q: <br /> fin Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Printfrype Name Signature Date <br /> ., 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone u: <br /> w Applicable Permit Numbers: <br /> ZU <br /> 1� INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> z <br /> PrinVType Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> i <br /> Transferred containers. cu R to : N orih Salt Lake,UT <br /> 8A.DoWgnded Facility: ea.mernote Facility: ®8C.Alternate Facility: 0 80.Alternate Facility: <br /> a Stericyde Inc-Autodave Sterlcyde Ino-Indneraflon Sterleyde Inc-Autodave Sterlicycle Inc-Autodave <br /> 4135 W.SV11FT AVE 90 NORTH t 100 1345 Doolittle Drive Ste C 2775 E 26111 STREET <br /> FRESNO,CA 93722 NORTH SALT LAKE CITY,UT San Leandro,CA 94577 VERNON,CA 90023 <br /> Z (559)275-0994 (M1)936-1555 (510)562- 1781 (323)362-3000 <br /> W TS31,TSIOST25 TSIOST22 Class V Incineradon Psm0 91 02 P-6,P-115 <br /> TREATMENT FACILITY:I certify that I have been authorized by the applicable state agency!to accept untreated medical wastes and that!have <br /> received the above indica w s in accordance with the requirement outlined in that,0 ' n. JUL � � 201® <br /> �y r <br /> Print/type Name Gte'fC Signature / Date <br /> 7if.. ..,ednu..snn+nw eD ALMnn I L -- <br />