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To:+1-2094688392 Page 8 of 14 2010-10-19 15:17:34 GMT-06:00 18003811139 From:SO CS Team 2 <br /> MEDICAL WASTE TRACKING FORM NUMBER <br /> 0-e-0 Stericycle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 14MO-234-0051 STANDARD MANIFEST 001-10-06-STD <br /> P,aRMbq hople.ReMrcMt RtA� Route #: 800 - 9 CBMTREC 800-424-9300 MDFROD9646 <br /> 1.Generator's Name,Address and Telephone Number C <br /> ATTN: Bobbie <br /> EGO-STOCA'PUN PROF CE)IM <br /> 6529 INGLEWOOD AVE STE B3 <br /> STOCKTON, CA 95207 <br /> 209 478-3886 3/23/2010 <br /> CusTomER NumsER 6038268-003 GeNeFmTows REersTRATtoN# <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C.NO.OF 21D. VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, CONTAINERS <br /> UN 3291,PG II TB57 - 90 Gal Tub (Bio) (12 Cu ft) Cir Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, TB49 - 3-1 Gal Tub (Bio) (4.9 Cu ft) <br /> UN 3291,PG II Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, TB14 - 44 Gal Tub(Bio) (3.9 Cu ft) <br /> I O UN 3291 PG II Cu Ft. <br /> UN 3291T DD MEDICAL WASTE,n.o.s.,6. T 0 Gal Tub(Bio) (2.7 cu ft)) .- <br /> Ft. <br /> W REGULATED MEDICAL WASTE,n.a.s.,6. . TB15 - 20 Gal Tub (Patai) (2.7 cu ft) Cu Ft <br /> W UN 3291,PG 11 <br /> (� REGULATED MEDICAL WASTE,n.o.s.,6.2. <br /> UN 3291,PG If TY15 - 20 Gal Tub (Chemo) (2.7 Cu ft) Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,61, <br /> UN 3291,PG 11 Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s-6.2, <br /> UN 3291,PG If Cu Ft. <br /> et Cu F <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTAL$ ® C u Ft, <br /> 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 international and national governmental regulations." <br /> 1Printed/ryped Nang //A s _Signature to •?—Z 3✓o <br /> 4.TRANSPORTER 1 ADDRESS: Phone#: <br /> (559) 275 - 0994 <br /> Stericycle, <br /> Inc. Applicable Permit Numbers: <br /> 4135 West Swift Ave. This is Thr=ough r=ough shipment <br /> Z& Fresno,Ca 93722 <br /> d a TRANSPORTER C FiCATION: Recei of medical waste as described abo <br /> Print/Type Name Signature <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORT R62 ADDRESS: Pho #: <br /> a <br /> ga Applicable Permit Numbers: <br /> 8 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#: <br /> a� <br /> o <br /> Applicable Permit Numbers: <br /> ij <br /> Q Q INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Lu <br /> - Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transfe contalners Cu ft to *. or%Sall Lake UT <br /> SA-Designated Designated Facility: ae.Alternate Facility: GC,Alternate Facility, 60.A14ernats 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 26TH STREET <br /> LL FRESNO,CA 93722 NORTH SALT LAKE CITY.UT SUN VALIXY,CA 91352 VERNON,CA 90023 <br /> (559)275-0994 (801)936- 1555 (6 18)SW-6937 (323)362-3000 <br /> TS31,T5/OST25 TSIOST22 Class V Indnetatlon Permlitt 91- 2 P-G,P-115 <br /> LU TREATMENT FACILITY:1 certify that) have been authorized by the applicable slate age accept untreated medical wastes and that I have <br /> received the above indica w s in accordance with the requirement in th t rization. AR Z 3 2 <br /> Print/rype Name ef&je Signature Date <br /> ( <br /> ORIGINAL <br /> Um qnja <br />