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To:+1-2094688392 Page 7 of 14 2010-10-19 15:17:34 GMT-06:00 18003811139 From:SQ CS Team 2 <br /> MEDICAL WASTE TRACKING FORM NUMBER <br /> 00 <br /> %0,-0 5tericycle* IN CASE OF EMERGENCY COMACT.CHEMTREC 1.800-234-0051 STANDARD MANIFESTo0t-io-06-STD <br /> SaoA <br /> gated,q pork.RAed,q Rkl; <br /> 1. Generator's Name,Address and Telephone Number - <br /> ATTN: Bobbie II ! I I f I I I I I <br /> ECO—STOCKTON PROF CENTER <br /> 6529 INGLEWOOD AVE STE B3 <br /> STOCKTON, CA 95207 <br /> b ______412 2010 <br /> CusTomER Numnen GENERATOR'S RE613TR2 <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2. CONTAINERS <br /> UN 3291,PG 11 Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s-6.2, <br /> UN 3291.PG II TI34 9 - B t Cu Ft. <br /> pE REGULATED MEDICAL WASTE.n.o.s..6.2, <br /> Q UN 3291.PG II --161444 G 15.4 Cu ft Cu Ft. <br /> Q REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG II x1321 - 20 Yub(13i.o) (2.7 cu ftp Cu Ft. <br /> W REGULATED MEDICAL WASTE,n.o.s.,6.2. <br /> W UN 3291,PG 11 T 0 Gal Tub Path 2.7 cu ft Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG 11 al o Cu Ft. <br /> REGULATED MEDICAL WASTE,n,o.s.,6.2, <br /> UN 3291,PG It Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG 11 Cu Ft. <br /> Cu Fl.i <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignmeru are fully and accurately TOTALS Cu Ft <br /> j described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and <br /> are in all respects in proper condition for transport according to applicable intemational and national governm eg ion " <br /> Pill e?A <br /> r r� <br /> f IPrintecirl ped Name —Signature Date <br /> 4.TRANSPORTER 1 ADDRESS: Phone 3: �5�q <br /> Stericycle, Inc. " <br /> Applicable PehlCitT jb&?5 - 0994 <br /> -x ® 4135 Sent Swift Ave. <br /> 5� r® g This is a Through Shipment <br /> ICE Z9 TRANSPORTEFT69 O 'R� maaddical waste as described above. <br /> ~ PrinVfype Name / g <br /> i nature � Date <br /> 5.INTERMEDIATE HA LER 2/TRANSPORTER 2 ADDRESS: Phone 8: <br /> N <br /> 115 <br /> Applicable Permit Numbars: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Printflypo Name Signature Date <br /> Ly 8.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone A: <br /> a CC Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION. Receipt al medical waste as described above. <br /> I <br /> H <br /> x <br /> fE PrinUType Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> ® —1 0 <br /> 8A.Designated Facility: 88 a;-Ilay. 8C.Alternate Facility: 80.Alternate Facility; <br /> J STERICYCLE INC STERICYCLE INC STERICYCLE INC STERICYCLE INC <br /> a 4135 W.SWIFT AVE 90 NORTH 1100 VVEST 9053 NORRIS AVE. 2775 E 28TH STREET <br /> zFRESNO,CA 93722 NORTH SALT LAKE CITY.UT SUN VALLEY,CA 91352 VERNON.CA SM23 <br /> W (559)275-09 (801)93fi-4S5S (818) -6937 (323) •3000 <br /> T331,TWOST26 TSfOST22 Claw V Indnerallon Permllilill 91 P-6,P-115 <br /> Q <br /> w TREATMENT FACILITY:i certify that I have been authorized by the applic stat y to accept untreated medical wastes and that I have <br /> Imo- received the above!pIdeatepWkstes in accordance with the requir utlined tion. a <br /> PR 2-0 2010 <br /> 1R'y <br /> Prbnpe Name 49WO94V A,4f Signature r ' Date t' <br /> i <br /> 000. 98 <br /> ANAL <br />