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To:+1-2094688392 Page 6 of 14 2010-10-19 15:17:34 GMT-06:00 18003811139 From:SO CS Team 2 <br /> MEDICAL WASTE TRACKING FORM NUMBER <br /> Do <br /> ®!® Stericyde' IN CASE OF EMERGENCY CONTACT.CHEMTREC 1-600.424-0300 STANDARD MANIFEST 001.10-06-STD <br /> m ft-K Pe We."*1 ft A <br /> Route 0: 800 - <br /> t.Generator's Name,Address and Telephone Number <br /> ATTN: Bobbie 1! I 1 11 111 11 1 ! ! I!oil III <br /> ECO-STOCRTON PROF CENTER <br /> 6529 INGLEWOOD AVE STE B3 <br /> STOCKTON, CA 95207 <br /> 209 478-3886 5 18 201( <br /> CUSTOMER NuMaER6038268-003 GeNERATows REof MATRON 0 <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO.OF 21). VOLUME <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> CONTAINERS <br /> 6.2,PGII Cu Ft. <br /> UN3291,Regulated Medical Waste,n.o.a, <br /> 6.2,PGII TB49 — 37 Gal Tub Bio 4.9 cu ft) Cu Ft. <br /> CC UN3291,Regulated Medical Waste.n.o.s.. <br /> ® 6.2,PGII 4 G Cu Ft. <br /> aUN3291,Regulated Medical Waste,n.o.s., <br /> M 6.2.PGII TH21 20 Gal Tub(Bio) (2.7 cu ft) Cu Ft. <br /> W UN3291,Regulated Medical Waste,n.o.s., <br /> ILI Z 6.2,PGII _ Cu Ft. <br /> UN3291,Regulated Medical Waste,n.os., <br /> 6.2,PGIIr.ra.1Cu Ft. <br /> UN3291,Regulated Medical Waste,n.Ds., <br /> 6.2,PGII Cu Ft. <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2,PGII Cu Ft. <br /> Cu Ft. <br /> 3.Generator's Certification;-1 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 classified,packaged,marked and labetted/ptacarded,and <br /> Tare in all respects in proper condition for transport according to applicable international and stational governmental regulations' <br /> Ai1Printedr'fypedd Name Signature O « a <br /> 4.TRANSPORTER 1 ADDRESS: Phone If: <br /> rAiu - <br /> � Stericycle, Inc. Applicable Per u%Lr�75 0 <br /> 4135 West Swift Ave. <br /> g Fresno,Ca 93722 This is a Through Shipment <br /> CIE Z4 TRANSPORTER CERTIFICATION- eceipt of medical waste as described ab <br /> a <br /> PrinV'Typa Name � Signature Dat® <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#: <br /> c Applicable Permit Numbers: <br /> w <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Prinirrype Name Signature Data <br /> 6.INTERMEDIATE HANDIER 3/TRANSPORTER 3 ADDRESS: Phone tt: <br /> w4 <br /> w Applicable Permit Numbers: <br /> w <br /> P INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above, <br /> z� <br /> a <br /> — Printrtype Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> e BA.B»aslgnated Facility: aa.Aftwmts Facility: SC.Attemate Facility: U 80.Anernate Facillty: <br /> j! Stedcyde Inc-Autadave Stedcyde Ino Indneradon Stedcyde Inc-Autodave Stsdcyde Inc-Autodave <br /> a 4135 W.SWIFT AVE 90 NORTH 1100 1345 Doolittle Drive Ste C 2775E 26TH STREET <br /> FRESNO,CA 93722 NORTH SALT LAKE CITY,UT San Leandro,CA 94577 VERNON.CA 90023 <br /> Z (559)275-0994 (801)936- 1555 (610)562- 1791 (323)362-3000 <br /> TS31,TSIOST25 TS/OST22 Class V IndneraWn Pemro 91 1 <br /> 02 P-6,P-115 <br /> cr TREATMENT FACILITY: e ' that I have been authorized by the applica tate to accept untreated medical wastes and that I have <br /> H received the abov to tes in accordance with the require fined i aeon. ®® / 209®r� <br /> `°e� - mac�- M 1 S 2 lU <br /> Print/Type Name Q� l ryieV���C� Signature Date- MAY �' <br /> Goo Q:a3 <br />