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To:+1-2094688392 Page 5 of 14 2010-10-19 15:17:34 GMT-06:00 18003811139 From:SO CS Team 2
<br /> MEDICAL WASTE TRACKING FORM NUMBER
<br /> ®!41 Stericycle' IN CASE OF EMERGENCY CONTACT.CHEMTREC 1-800424-9300 STANDARD MANIFEST 001-10-0e-STO
<br /> ®Ip "°"ef°'0,,,,,'.R- th°. Route #: 800 - 8 MDFRO09I LB
<br /> 1.Generator's Name,Address and Telephone Number II I I I I
<br /> ATTN: Bobbie III I I I I I II I II I I
<br /> ECO-STOCKTON PROF CENTER
<br /> 6529 INGLEWOOD AVE STE B3
<br /> STOCKTON, CA 95207
<br /> (209) 47B-3866 6/15/201(
<br /> CUSTOMER NUMBER 6038268—003 GENERATOR'S REGISTRATION 9
<br /> 2A.DESCRIPTION OF WASTE 213. CONTAtNERTYPE 2C. NO.OF 20- VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., CONTAINERS
<br /> 6.2.PGII T1357 - 90 Gal Tub (Bio) (12 cu ft) Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.a.s., T049 - 37 Gal Tub (Bio) (4.9 cu ft)
<br /> 6.2.PGII Cu Ft.
<br /> ®
<br /> 6.2,
<br /> 3229G111 Regulated Medical Waste.n.o.s., T014 - 44 Gal Tub(Bio) (5.9 cu tt)
<br /> Cu Ft.
<br /> Q UN3291,Regulated Medical Waste.n.o.s., T 21 20 Gal Tub(Bio) (2.7 cu ft)
<br /> W 6.2,PGII Cu Ft.
<br /> W UN3291,Regulated Medical Waste,n.o.s., TS15 - 20 Gal Tub (Path) (2.7 Cu ft)
<br /> W 6.2,PGII _ Cu FL
<br /> W- UN3291,,Regulated MedicalWaste,n.o.s.,_ TY15— 20`Gal Tub' -(Chemo)--(Z.7"cu-ft) - -
<br /> 6.2;PGII Cu Ft.
<br /> UN3291,Regulated Medical.Waste,o.o.s.,
<br /> 6.2,PGII Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII
<br /> Cu FI.
<br /> Phartnaceutical Waste CuFI
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fatly and accurately TOTALS 10 Ft
<br /> described above b the proper shipping name.and are classified,packaged,marked and labelfed/placardad,and
<br /> are in all respects in proper condition for transport according tog '
<br /> applicable international and national government egulations
<br /> .Printed/Typed Name Gil 1 Signature Date A/0
<br /> r 4.TRANSPORTER 1 ADDRESS: Pion#: (559) 275 - 0
<br /> 1 ¢ Stericycle, Inc.
<br /> Applicable Permit Numbers:
<br /> i ¢ 9135 West Swift Ave. is is a Through Shipment
<br /> Fresno,Ca 93722
<br /> a q TRANSPORTER C RTIFICATION: t*t of medical waste as described above. /
<br /> ~ Prtnt/7ype Name Signature r' Daae
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Perone d:
<br /> N
<br /> Eg g Applicable Permit Numbers:
<br /> go
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone e:
<br /> Sw Applicable Permit Numbers:
<br /> c a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Pnnt/iype Name signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> (M4J35W,SWFTAVE
<br /> Transferred containers, cu ft to : North SaltLake,UT
<br /> Designated Facility: 811Alt te Facility: • ®9C.AlternateFacility: e®.Alternate Facility:Stericyde Inc-Autodave Stericyde Ino•In ineration Sterlcyda Inc-Autodeve Stertcyda Inc-Autodave
<br /> 90 NORTH 1100 1345 Doolittle DrNa Ste C 2775 E 26TH STREET
<br /> U4. FRESNO,CA 93722 NORTH SALT LAI<E CITY,UT San Leandro,CA 94577 VERNON,CA 90023
<br /> (559)27S-0994 (601)936- 1555 (510)S62- 1781 (323)362-3000
<br /> UJI TS31.TSIOST25 TSIOST22 Class Incineration PernIM 91 02 P•6,P-115
<br /> a
<br /> W TREATMENT FACILITY: I certify that I have been authorized by the applicabl ea accept untreated medical Wastes and that I have
<br /> received the above indi W ,.rte in accordance with the requirem In t
<br /> l Print(Type Name /A�� `� � Signature v "s"* Date
<br /> i
<br /> i
<br /> UC103T4
<br /> rptR a Cid 14-Jut•-2010 ORIGINAL
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