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To:+1-2094688392 Page 11 of 14 2010-10-19 15:17:34 GMT-06:00 18003811139 From:SQ CS Team 2 <br /> T rPl � -200— .— - - <br /> ®® MEDICAL WASTE TRACKING FORM NUMBER <br /> 410 Stericycle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800-234-0051 STANDARD MANIFEST oot-to-o6-STD <br /> %6 aka: <br /> 1,Generator's Name,Address and Telephone Number <br /> ATTN: Bobbie <br /> ECC?-STOCR'I'ON PROF CENTER <br /> 6529 INGLEWOOD AVE STE B3 <br /> STOCKTON, CA 95207 <br /> 478-3086 12/29/2005 <br /> CUSTOMER NUMBER � - _ GENERATOR's REGtsmAnom O <br /> 2A.DESCRIPTION OF WASTE 29. CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, CONTAINERS <br /> UN 3291,PG II _ Cu Ft, <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 329 b,PG ii TB49 - 37 Gal Tub Brio) J4.9 cu ftj Cu FL <br /> CC REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> Q UN 3291,PG II T014--- 44 Gal Tubt8ioi 15.9 cu Lt Cu Ft. <br /> Q REGULATED MEDICAL WASTE,n.o.s.,6.2. <br /> = UN 3291,PG II 821 - Gal Tub(bio) (2.7 cu ft) Cu Ft. <br /> LU REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> W UN 3291,PG II T015 - 20 Gal Tub (Fath2 JZ.7 Cu ft) Cu FL <br /> REGULATED MEDICAL WASTE,n.o.s..6.2. <br /> UN 3291,PG II _ <br /> Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG 11 <br /> Cu FL <br /> REGULATED MEDICAL WASTE.n.o.s.,6-2, <br /> UN 3291,PG II Cu Ft. <br /> Cu Ft. <br /> 3.Generatoer Certification:"1 hereby declare that the contents of this consignment are fully and accurately T®TALS 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 international and national governmental regulations" <br /> \ 6 <br /> XPrinted/ryped Name Signature Date <br /> 4.TRANSPORTER 1 ADDRESS: VPhone A: 7 <br /> 5tericycle, Inc. Applicable Parrl�ii�R�IS�r1j.7-5 - 0994 <br /> 4135 West Swift Ave. <br /> a. X22 This is a Through Shipment <br /> Z TRANSPORTERIrl, <br /> l" O . Receipt of medical waste as describ e. <br /> a e 111 _'-1�i <br /> PrinVWpe Name Signature ` Date— t X L <br /> S.INTERMEDIATE HANULER 2/;TRANSPORTER 2 ADDRESS: Phone q: <br /> Zr-- Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> e, 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#: <br /> w a a Applicable Permit Numbers: <br /> QQ <br /> Wz INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> T.DISCREPANCY INDICATION <br /> } 8A.Daatgrurteq Facility: ae,AtternaTe Faclilry: C.Alternate Facility: 80.Alternate Faclnty: <br /> h STERICYCLE INC STERICYCLE INC STERICYCLE INC STERICYCLE INC <br /> 4135 W.SIMFTAVE 90 NORTH 1100 VVEST 9053 NORRIS AVE, 2776 E 26TH STREET <br /> FRESNO,CA 93722 NORTH SALT LAKE CITY.UT SUN VALLEY,CA 91352 VERNON,CA 90023 <br /> w (559)275.0994 (801)936.1355 (818)504-6937 (323)362-3000 <br /> 5 - <br /> - TS311,TSiOST25 TS/OST22 Class V Incineration Parrift 91 02 P-13.P-11 cS <br /> M 0TREATMENT FACILITY: I ce t I have been authorized by the appliea age apt untreated medical w MaNdc.if I have <br /> I-- received the above ind; was n accordance with the requirement d' Iz <br /> Print/Type Name 4 Signature Date <br /> 1 L <br />