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To:+1-2094688392 Page 13 of 14 2010-10-19 15:17:34 GMT-06:00 18003811139 From:SO CS Team 2 <br /> twr�mw ` MEDICAL WASTE TRACKING FORM NUMBER <br /> ®` <br /> ®® SteNCyCI@' IN CASE OF EMERGENCY CONTACT;ClfEMTREC 1-800-234-W5T STANDARD MANIFEST 001-to-WSTO <br /> •.• na.%wv ft pl.s.*.j®.k1: uta : 800 - 7 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN: Bobbie it l i i II i l l l i <br /> ECO-STOCKTON PROF czrm <br /> 6529 INGLEWOOD AVE STE B3 <br /> STOCKTON, CA 95207 <br /> 209 478-3686 11/312009 <br /> CUSTOMER NUMBER 6038268-003 GENERATOR'S REGISTRATIONO <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s..6.2, CONTAINERS <br /> UN 3291,PG II TB57 - 90 Gal Tub (Bio) (12 cu tt) Cu Ft. <br /> REGUI.ATED MEDICAL WASTE,n-o.s.,6.2, <br /> N 3291,PG It TB49 - 37 Gal Tub (Bio) (4.9 Cu ft)U <br /> pC Gu FL <br /> REGULATED MEDICAL WASTE,n.o.s..6.2, <br /> Ip UN 3291,PG II TB14 - 44 Dal Tub(814) (.5.9 cu Lt) Cu Ft. <br /> Q REGULATED MEDICAL WASTE,n.o.s.,6.2, T821 - 20 (dal Tub(Rio) (2.7 cu ft) <br /> UN 3291,PG II Cu Ft. <br /> - <br /> W REGULATED MEDICAL WASTE,n.o.s.,6.2, TB15 - 20 dal Tub (Path) (2.7 cu ft) <br /> W UN 3291.PG II Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291.PG II TY15 - 20 Gal Tub (Chemo) (2.7 cu ft) 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 Cu Ft. <br /> Cu Ft. <br /> 3.Generator's Certflicalion:"I hereby declare that the contents of this consignment are fully and accurately TOTALS 0- T Cu Ft. <br /> described above by the pr r shipping name,and are classified,packaged,marked and labelted/placarded,and <br /> are in all respects in prope Condition for transport according to applicable international and national g mmental regulations" <br /> iPrinted/Typed Name �s `v'1 Signatur <br /> 4.TRANSPORTER 1 ADDR S: Phone S: <br /> SteriCyCle, Inc. Applicable Permi`ittNuum0994 <br /> Numb59)ers: <br /> - <br /> I a 0 4135 West Swift Ave_ r11is 2. is a Through Shipment <br /> ern Fresno,Ca 93722 <br /> a 4 TRANSPORTER CERTIFICATION: Receipt of medical waste as deLrbabove.ir <br /> t <br /> ~ PrinMpe Name� Signature Date 1!1 3/' <br /> #!�®9 <br /> S.INTERMEDIATE HANDLER /TRANSPORTER 2 ADDRESS: Phone p: <br /> N <br /> a: Applicable Permit Numbers: <br /> ge, <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> RX <br /> �- Printlfype,Name Signature Date <br /> �,ur 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 4: <br /> 15.1 w Applicable Permit Numbers: <br /> S INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transfermd eorfthwm. cu R to : Nolth San Lake UT <br /> r 8A.Designated Facility: ❑88.Alternate Facility: ®SC.Alternate Facility: n BD.Ahernate Facility: <br /> J STERICYCLE INC STERICYCLE INC STERICYCLE INC STERICYCLE INC <br /> Q 4135 W.SWIFT AVE 90 NORTH 1 IGD WEST 9053 NORRIS AVE, 2775 E 26TH STREET <br /> FRESNO,CA 93722 NORTH SALT LAKE CITY,UT SUN VALLEY.CA 91352 VERNON.CA 90023 <br /> z (559)275-0994 (801)936-1555 (8 16)504-6937 (323)362-30D0 <br /> UJI T$3 i.TS1OST25 TSIOST22 Class V Indnerallon permog 91 P 6,P-115 <br /> a <br /> W TREATMENT FACILITY:I ce ity that I have been authorized by the applicable state agency tp ccept untreated medical wastes and that I ave <br /> II- received the above in i. a in accordance with the requirement ot1Ui that o' ation, Nov 3 200 <br /> Ate^ +*- <br /> Print/Type Name V cR Signature Date <br /> 7 67 <br /> ps <br /> ___ NA M--WWI. ORltaINAL <br />