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To:+1-2094688392 Page 9 of 14 2010-10-19 15:17:34 GMT-06:00 18003811139 From:SO CS Team 2
<br /> MEDICAL WASTE TRACKING FORM NUMBER
<br /> O®o O SteriCj/cle' (N f,�t�SE AF E ER Y CON CT: STANDARD MAN( e T 0 1- 0.06-STD
<br /> ®o PkVCO.-
<br /> 1.
<br /> . U e - �' _ � E� t� ° 4-9300 MD6'12E�J�9��M
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ATTN: Bobbie
<br /> ECO-STOCKTON PROF CENTER
<br /> 6529 INGLEWOOD AVE STE B3
<br /> STOMTOR, CA 95207
<br /> (209) 478-3686 2/23/2010 '
<br /> CUSTOMER NUMBER 6038268-003 GENERATORS REGrSTRAT1
<br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO.OF 2D. VOLUME
<br /> REGULATED MEDICAL WASTE,n.o.s.,62. TB57 - 90 Gal Tub .(Rio) (12 c D CONTAINERS
<br /> UN 3291,PG 11 Cu FI.
<br /> REGULATED MEDICAL WASTE,n.c.s.,6.2, T04 9 - 77 Gal TUL5 Mio Cu
<br /> UN 3291,PG 11 Cu Ft.
<br /> CC REGULATED MEDICAL WASTE,n.c.s.,6.2, T914 - 44 d 0 CU
<br /> Q UN 3291,PG 11 Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> CC UN 3291,PG 11 Cu Ft.
<br /> W REGULATED MEDICAL WASTE,n.o.s.,6.2, T1311b Gal Tujj (PatJ113cu
<br /> W
<br /> UN 3291,PG II Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2. S - 20 Gal Tub (Chemo) (2.7 cu ft)
<br /> UN 3291,PG II Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> UN 3291,PG II Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6,2,
<br /> UN 3291,PG II X I Cu FL
<br /> Pharnaceut,ical Waw e
<br /> 1 Cu Ft.
<br /> 3.Generator's Certiflcation:"I hereby declare that the contents or this consignment are fully and accurately Cu Ft.
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and
<br /> are int all respecls in proper condition f r ranspon actor ng to,applicable international and natlonal governmen e lations" r X42
<br /> IPrinted/T ed Name e Signature Date
<br /> tr 4.TRANSPORTER 1 AD - Phone a: Lbmij 2 15 -
<br /> W-EHIcycle, Inc. 1-14
<br /> FW- pplicable Permit Numbers:
<br /> ® 4135 West Swift Ave. .Ave. • This is a Through Shipment
<br /> < d. Fresno,Cal 93722
<br /> OL a~ SPORTER FTFICATION:Xr�104::Ad
<br /> t of medical waste as describedabove.
<br /> PrinUTypeNme Sig ature
<br /> Date
<br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone 4:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER ITRANSPORTEA CERTIFICATION: Re ip fm wes a as described above.
<br /> a ,
<br /> Printli'ype Name Signature Date
<br /> .; 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone H:
<br /> 14;
<br /> Applicable Permit Numbers:
<br /> Uj
<br /> o
<br /> 'as INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> - Pdnt/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Tmnstemed emalmrs, ou R to , North Sall Lake, UT
<br /> } R®A.Designated Facility: 60.Attemate Facility: n 8C.Alternate Facility: ®80.Alternate Facility:
<br /> I� STERICYCLE INC STERICYCLE INC STERICYCLE INC STERICYCLE INC
<br /> zj 4135 W.SWIFT AVE 90 NORTH 11 W WEST 9053 NORRIS AVE. 2775 E 26TH STREET
<br /> Q FRESNO,CA 93722 NORTH SALT LAKE CITY.L T SUN VALLEY,CA 91352 VERNON.CA 90023
<br /> LL' (559)275.0994 (801)936- 1555 (818)504.6937 (323)362-3000
<br /> TS31.MOMS TSIOST22 CIa99V Indnerafion Pe 1-02 P-6,P-115
<br /> UJI
<br /> UJ TREATMENT FACILITY:I C rti that I have been authorized by the applicable to age accept untreated medical wastes and that I have
<br /> H received the above 1 ed s in accordance with the requireme d in th t nation. Z -3 2010
<br /> PrinMpe Name_ •� Signature - Date FEBGD U
<br /> 6%ran R A 7
<br /> rIAf4WWMQ6IA1 22-fab2MO ORIGINAL
<br />
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