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To:+1-2094688392 Page 12 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®ti Stericytle' IN CASE OFF14EEUGEeNC COT T:CH�MTREC1-elm-234-0051 STMDFR008Q 710- -STD <br /> .. R tC l - 3 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTER: Robbie 1 r <br /> ECO-STOCRTON PROF CENTER <br /> 6529 INGLEWOOD AVE STE B3 <br /> STOCKTON, CA 95207 <br /> (209) 478-3886 12/1/2009 <br /> i <br /> i <br /> 6039260-1003 <br /> CUSTOMER NumoER GENERA-FOR-s REGtmAYION 0 <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, TB57 - 90 Gal Tub (Bio) (12 Cu ft) CONTAINERS <br /> UN 3291,PG II Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, TH49 - 37 Gal Tub (Bio) (4.9 Cu ft) ! <br /> i UN 3291,PG II Cu Ft. <br /> CC UN 3291REGULATED MEDICAL WASTE,n.o.s..6.2. - Ga (Bio) ( Cu 'ft) <br /> _ Cu Ft. <br /> Q REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG 11 Cu Ft. <br /> WREGULATED MEDICAL WASTE,n.o.s.,6.2, THIS - 20 Ga Tu Pat ) Cu ft) <br /> W UN 3291,PG 11 Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, TY15 - 20 ®al 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 /> i REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG 11 Cu Ft. <br /> Pharmaceutical Waste <br /> Cu Ft. <br /> 3.Generator's Certification:-I hereby declare that the contents of this consignment are fully and accurately TOTALS Do, <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)reguregulations."I I Printedfryped Name Signature !G LGG. ate <br /> 4.TRANSPORTER 1 � t'�jrCl@° Inc. <br /> Phone 9: <br /> W Applicable Permit Numbers: <br /> 4135 West Swift Ave. This is a Theough shipment: <br /> o Fresno,Ca 93722 <br /> a TRANSPORTER CEceipt of medical waste as described above. <br /> t <br /> Printlfype Name `Signature Date QZa It0 <br /> n <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone k: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> i <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#: <br /> SApplicable Permit Numbers: <br /> ZZ INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> - Pr1nMpe Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transftmd colmlainem, eu 0 to : Nonh San Lake,UT <br /> SA.Designated Facility: a®.Alternate Facility: ®aC.Alternate Facility: 0 so.Alternate FactlMy. <br /> STERICYCLE INC STERICYCLE INC STERICYCLE INC STERICYCLE INC <br /> 4135 W.SWIFT AVE 90 NORTH 1100 VIVEST 9063 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)936-1655 (818)604-6937 (323)362-3000 <br /> 7531,TS/t�ST 25 T5/OST12 Class V wig on PeLu <br /> 91- 2 P-6,P=115 <br /> LLA <br /> a TREATMENT FACILITY: cert that I have been authorized by the appticablerstate a y o accept untreated medical Wastes and that I have <br /> F- received the above i ate v tes in accordance with the require(Oenu= )lined in i tion. rr <br /> PrinUTypeName �/gGd�l�vt��l Signature Date ®E4 ® 1 2009 <br /> 't _t it <br /> \ rptfde twl 3a ORIGINAL -- -- — - <br />