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MEDICAL. WASTE TRACKING FORM NUMBER <br />0 ®• S�@t`ICyC�P.° *ASE OF EMERGENCY CONTACT: CHEMTREC 1 -BOD -424- STANDARD MANIFEST 001 -10 -06 -STD <br />V R"fedhiii "pleReduda9114k: Route #: 123 – 23 CUSTOMER NO. 21132 MDF•ROOJX13 <br />i iransfelTed containers, CU R to <br />ORIGINAL <br />1. Generator's Name, Address and Telephone Number <br />ATTN-. 1111111111111111111111111111111111,111111111111111111 <br />BILL MDICAL f ZN= <br />1617 N CALIit'ORNIA ST <br />STOMM11r CA 95204- 6117 <br />(209) 451-9031 <br />11/21/201.7 <br />CUSTOMER NUMBER (5111852-001. GENERATows REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B• CONTAINERTYPE <br />2C. NO. OF <br />21). VOLUME <br />Regulated Nodical Waste, n.o.s„ <br />623PGIj <br />T805 _ 40 Gal Tub (Bio) (5.3 cut ft) <br />CONTAINERS <br />Cu Ft. <br />Regulated Medical Waste, n o.s,, <br />6.2, PGI <br />TB49 _ 37 Gal Tub (Bio} (4.9 cu ft) <br />Cu Ft. <br />I= <br />UN3291 Regulated Medical Waste, n.o.s , <br />14 44 Gal Ttxi? (13itx} (5'. 9 cu ft) <br />® <br />6.2, PGI <br />. Cu Ft. <br />Ki <br />UN3291,Regulated Medical Waste, n,o.s , <br />TB21– (Blo) /TP15-- (Path) /TY15– (CheM¢) 2O Gal Tetb (2.7cu rT) <br />t1: <br />Cu Ft. <br />623Pail Regulated Medical Waste, n.o.s., <br />WB31– (Bio) /WP31– (Path) /WG31– (Chemo)31 Gal. Tub (4.14CUFT <br />Cu Ft, <br />lZ <br />Regulated Medlcai Waste, n.o.s., <br />62, UN3291 Regulated <br />W1343^ (Bio) /PW43– (Path) /CW'43– (Cbemo) Gal. Tub (5.7CUFT) <br />Cu Ft. <br />UN3291 Regulated Modica] Waste, n.o.s, <br />6.2, PGII <br />KRB— •- Biosystems Cardboard Box (4.2 cut ft) <br />Cu F1 <br />UN3291 Regulated Medical Waste, n.o s, <br />6.2, PGII <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.21 PGII <br />Cu Ft <br />3. Gen aIt Certification:'? hereby declare that the contents of this consignment are fully and accurately <br />TOTALS 1 <br />". Cu Ft. <br />descr a bone'b the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are all r pacts in proper condition for transport a1ccjor�(diyng(�torap ilcabie international and national ver a al <br />ui tions:' <br />i tl t l `� iii <br />t 7 <br />%a edliypod Name [U Sl tura <br />e} <br />cc <br />4. TRANSPORTER 1 ADDRESS; <br />Phone #: (866) 7$3-7422 <br />Stet:icycle, Inc. ® This is a Through shipment <br />Applicable Permit Numbers: <br />a o <br />4135 A. Swift Ave <br />Hauler Reg# 3400 <br />MIL <br />.-Xreano,cA 93722 <br />a. <br />TRANSPO CERT ICA t ecelpt of ircat waste as described <br />r6in <br />Pririmpe Nam Signature <br />Date `f <br />5. INTERMEDIATE HAND 2 / TRANSPORTER 2 DRESS: <br />Phone #: <br />Applicable Permit Numbers <br />o�n <br />N <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />PrintlType Name Signature <br />Date <br />LU <br />& INTERMEDIATE HANDL$R 3 /TRANSPORTER 3 ADDRESS: <br />Phone #. <br />9 °ui <br />Applicable Permit Numbers: <br />'no a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />a <br />– <br />Print/iype Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />>» <br />!•�— <br />8A. Designated FacTlity: 8a. Attemate Facility: ❑ 80. Attemate Facility: ❑ so. Alternate Facility: <br />Stericycle, Inc. Starlcycle. inc. Sterlcycle, Inc. <br />Q <br />4186 VY. 513 N. Foxboro Dave 1551 Shelton DrIo <br />NEORTtz <br />u- <br />Presna,CA North Sal Lake, UT 840% Hollister, CA 85023 <br />Z <br />(866)783-7422 (886)783-7422 (866)783-7422 <br />g <br />Ts/OST27NOV 212017 3A448-.0-36 TS,•OST 83 <br />w <br />TREATMENT FACI ,•,��11 �c�� that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />I— <br />received the above in 1 aietStes In accordance with the requirement outlined in that authorization. <br />Print/rype Name Signature <br />Date <br />i iransfelTed containers, CU R to <br />ORIGINAL <br />