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To:+1-2094688392 Page 14 of 14 2010-10-19 15:17:34 GMT-06:00 18003811139 From:SO CS Team 2 <br /> MEDICAL WASTE TRACKING FORM NUMBER <br /> •®® Stericycle, IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-WO-234.0051 STANDARD MANIFEST 001-10-M-STD <br /> • wmKtu,r r..a..Rod-ft as <br /> Flouts : 800 - 9 MDER008ZON <br /> I.Generator's Name,Address and Telephone Number <br /> ATTN: Bobbie I �� <br /> ECO-STOCKTON PROF CENTER <br /> 6529 INGLEWOOD AVE STE B3 <br /> STOCKTON, CA 95207 <br /> (209 478-3886 10/6/2009 <br /> Cusroslea Nurael:R - n - _ Q GeaaRAroR•s ReolsrnAnw+N <br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> REGULATED MEDICAL WASTE,mos.,6.2. CONTAINERS <br /> UN 3291,PG II T1357 - 90 Gal Tub (Bio) (12 Cu ft) Cu Ft. <br /> REGULATED MEDICAL WASTE.n.o.s.,6.2. <br /> UN 3291.PG II T849 - 37 Goll Tub (Birt) (4-9 CU tt) Cu Ft. I <br /> Q REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> Q UN 3291,PG II TB14 - 44 Gal Tub(Bi.0) (5-9 Cu ft) Cu Ft. <br /> Q REGULATED MEDICAL WASTE,n.o.s..6.2, TB21 - 20 Gal Tub(Bio) (2.7 Cu ft) <br /> Ix UN 3291,PG II Cu Ft. <br /> W REGULATED MEDICAL WASTE,n.o.s.,6.2. <br /> tZ UN 3291.PG II TB15 - 20 Gal Tub (Path) (2.7 Cu ft) Cu Fc <br /> C7 REGULATED MEDICAL WASTE,n.o.s.,6.2. <br /> UN 3291.PG II TY15 - 29 Gal Tub (Chemo) (2.7 cu Et) Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG II a Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG II Cu F1. <br /> Cu Ft. <br /> 3.Generators Certification:`I hereby declare that the contents of this consignment are fully and accurately TOTALS110 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 /> I <br /> " <br /> 1 IPrintedlryped Nam® Signature ate ZD — <br /> 4.TRANSPORTER 1 ADDRESS: Phone N:IX (599) 275 - 0994 <br /> r SteriCycle, Inc. Applicable Permit Numbers: <br /> 4135 Rest Swift Ave. <br /> a is is a Through Shipment <br /> Gln Fresno,Ca 93722 <br /> a a TRANSPORTER CER FICATION: R of medical waste as described ab wre. <br /> gy- /'�► <br /> Print/Type Name d Signature Date V <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone 0: <br /> IRqe� Applicable Permit Numbers: <br /> o <br /> E <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described strove. <br /> a i <br /> PrintlType Name Signature Date <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 0: <br /> Applicable Permit Numbers: <br /> g a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Q�x <br /> - Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> i <br /> Transterired containers Cu fl to <br /> 84 Deeignated Facility: 88.Alternate Facility: 8C.Aftentata Faculty: 80.Altamate Facility: <br /> e---\STERICYCLE INC STERICYCLE INC STERICYCLE INC STERICYCLE INC <br /> 4135 W.SWAFTAVE 90 NORTH 1100 WEST 9053 NORMS AVE. 2775 E 26TH STREET <br /> FRESNO.CA 93722 NORTH SALT LAXE CITY, T SUN VALLEY,CA 91352 VERNON.CA 90023 <br /> (559)275-GM (801)936- 1655 (8 18)504-6937 (323)362-3000 <br /> Lu <br /> Lu TS31.TS/OST25 TS/OST22 Class V Indnerallon Perrffrft 91 02 P-6,P-115 <br /> t <br /> u3 TREATMENT FACILITY:I certify that I have been authorized by the applicable state agency t sept untreated medical wastes and that I have <br /> h received the above indica a in accordance with the requirement outs n hai H ation. ®CTO Z009 <br /> Pdnt/Type Name Signature Date <br /> I <br /> i <br /> ORIGINAL <br />