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To:+1-2094688392 Page 10 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®® Stericycle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800-234-0051 STANDARD MANIFEST 001-10-06•sT0 <br /> ®® Prateaft Nwpic Red"Risk: <br /> Route 800 <br /> 0 pq <br /> ® ®\+V 9 MDERQ0gXZ2 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTIJ: Bobbie <br /> ECO-STOCKTON PROF CENTER 1 tl 1 tt t <br /> 6529 INGLEWOOD AVE STE B3 <br /> STOCKTON, CA 95207 <br /> 209 478-3886 1/26/2010 <br /> CUSTOMER NUMBER E]0��2 68-003 GENERATOR'S REGISTRA7loN 0 <br /> 2A.DESCRIPTION OF WASTE 28• CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> REGULATED MEDICAL WASTE,rt.o.s•,6.2, CONTAINERS <br /> UN 3291,PG II TB57 - 90 Gal Tub (Bio) (12 cu ft) Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s..6.2. T849 3? f;,�l Tub (Bir,) (q,9 cu t t) <br /> UN 3291,PG 11 Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, TB 44 tial Tub(Bio) (.S.9 Cu tt) <br /> ® UN 3291,PG II Cu Ft. <br /> ~Q REGULATED MEDICAL WASTE,n.0.s.,6.2, 821 - 0 Gal Tub(Bio) (2-7 cu ftp <br /> Q UN 3291,PG 11 Cu Ft. <br /> W REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> W UN 3291,PG 11 T815 - 20 Gal Tub (PaM) (Z.7 cu ft) Cu Ft. <br /> • <br /> REGULATED MEDICAL WAST11.0 <br /> UN 3291,PG 11 TY15 - 20 tial Tt.tb (c:hetno) (2.7 pp ft) Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG II Cu Ft. <br /> REGULATED MEDICAL WASTE.n.D.s•,6.2, <br /> UN 3291,PG 1) Cu Ft. <br /> Pharmaceutical Waste 1 Cu F <br /> 3-Generators Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS cam.—7 Cu 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 intern tional and national governmental regulations <br /> .r <br /> PrintedRyped Name ` Signature ����A�Date - <br /> 4,TRANSPORTER 1 ADDRESS: Phone 0, t1 _ <br /> Steric ycle, Inc. Applicable Perm Nufiberss:7' 0994 <br /> 4135 ilieet Swift Ave. <br /> r <br /> Q® This is a T11rougtt Shipment <br /> � a trano,Ca93722 <br /> a TRANSPORTERIFICATIO :Receipt of medical waste as described above. <br /> C <br /> Print/Type Name ` Signature Date <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone k: <br /> g Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> RX <br /> IE- PrinUType Name Signature Date <br /> Z;W 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone ff: <br /> i. Applicable Permit Numbers: <br /> W 4 <br /> R3cc <br /> 2 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> 7-DISCREPANCY INDICATION <br /> Transferred containers cu ft to : North Saft Lake U <br /> y 6A.Designated Faculty: OR.Anemate Facility: ®6C.Alternats Facility; 80.Attsmate Facility: <br /> f- STERICYCLE INC STERICYCLE INC STERICYCLE INC STERICYCLE INC <br /> 4135 W.SWIFT AVE 90 NORTH 110®V4EST 9053 NORRIS AVE. 2775E 26TH STREET <br /> FRESNO,CA 93722 NORTH SALT LAKE CITY,UT SUN VALLEY,CA 91352 VERNON.CA 90023 <br /> 5-0934 (1301)936-1555 (818)504-6937 (323)362-3000 <br /> LU TS31,TS/OST-25 TS/OST22 Class V Incineration Permit#91 2 P-a,P-11 15 <br /> W TREATMENT FACILITY: I 09Aity that I have been authorized by the applicable state agen y accept untreated medical wastes and that I have <br /> received the above in d in accordance with the requirement In the Ization. <br /> JAN 6 2010 <br /> Pdnt/Type llama Signature ✓ t Date <br /> i <br /> 5 22 0 <br /> ORIGINAL <br /> —- --- ---- -- PMGYtAan.4fs�•J.r.l •rs..er...�mtn — -- - <br />