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®•! c MEDICAL WASTE TRACKING FORM NUMBER
<br />® ®® Ste1"ICyCie' SE OF EMERGENCY CONTACT: CHEMTREC 1-800-424- STANDARD MANIFEST 001 -10 -06 -STD
<br />.N�F*: a 0: 133 - 23 CUSTOMER NO. 21W MDFROOJS50
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<br />1. Generator's Name, Address and Telephone Number
<br />ATTN z Jtady oil
<br />I I
<br />litAIMISAW d ROS= MM GRP 1199
<br />4600 S TRACY BLVD
<br />TRACY, CA 95377- 8105
<br />(209) 836-4920 10/17/2017
<br />CUSTOMER NUMBER 6050692®006 GENERATOR,s REGISTRATION ff
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />6.23291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />TB05 - 40 Gal Tub (Bio) (5.3 Cu ft)
<br />CONTAINERS
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2. PGII
<br />TB49 - 37 Gal Tub (Bio) (it- 9 OG ft)
<br />Cu Ft.
<br />Cr
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />TB14 - 44 Gal TUb (Bio) f 5.9 >;u Lt)
<br />0
<br />Cu Ft.
<br />Q
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TB21- (BIG)/TP15- (Pard) /TY1S- (Chemo)20 coal Tub (2.7CUFT)
<br />cc
<br />6.2, PGII
<br />Cu Ft.
<br />W
<br />6.23291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />V831- (Bio) /NP31— (Path) /KC31— (Chemo) 31 Gal Tub (4.14CUFT)
<br />W
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2. PGII
<br />%x843- (Bio) /PK43- (Path) /CK43- (Chemo) Gal Tub (S.7CUPT)
<br />Cu FL
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />KRB_ - Biosystems Cardboard Box (4.2 Cu ft)
<br />Cu FL
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste. n.o.s.,
<br />6.2, PGII
<br />'
<br />Cu Ft.
<br />3. Generator's Certification: "I hereb declare that the contents of this consignment are fully and accurately T®7 ALS 111-
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<br />described
<br />described above by the prop s ippi g name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in proper on itio for transport according to applicable international and national government egulati S.
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<br />,Printed/Typed Na Signature Date
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<br />4. TRANSPORTER 1 ADORES Phone a: (866) 783-7422
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<br />SteCl le, Inc. ® This is a Through Shipment
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<br />Applicable Permit Numbers:
<br />4135 V. Swift Ave
<br />A
<br />Hauler RegAt 3400
<br />M Feesno,CA
<br />93722
<br />Fr
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<br />TRANSPORTR C IF TION: Receipt of medical waste as described above.
<br />cc
<br />~
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<br />Print/Type Name Signature Date `®s
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone p:
<br />Iwo
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />�-
<br />Print/Type Name Signature Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone p:
<br />LUa w
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Z�x
<br />-
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />r7l&A. Designated Facility: 8B. Alternate Facility: E] 8C. Alternate Facility: ❑ 8D. Alternate Facility:
<br />ftdayale, t M.. (rte, Stiertcyale, Inc.
<br />4135 W. SWR AVS 90 N, alxboro Drtve 1551 Sheltm DrIve
<br />Fresn oCA 93722 Nortlt Salt Lake. UT 841134 CA 95023
<br />83- 47 (866)783-7422 (M)7M77422
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<br />1.1
<br />_TSSW�*IIEORM 3A448-14-36 TSIOST 83
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<br />TREATS` f%I t certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />�ated
<br />receiveT•f tfi aSA wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type NaSignature Date
<br />:raeeaacrreua wru.auesuas cu n to
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