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— ®4 — -- — — - - -- — — — - MEDICAL WASTE TRACKING FORM NUMBER0.-?! stericycte' IN CASE OF EMERGENCY CONTACT: CMEMTREC 1 -800 -424 -MOO STANDARD MANIFEST 001 -10•06 -SM <br />Route 0: 100 - 25 CUSTOMER No. 21132 MDFROO95FN <br />ORIGINAL <br />1. (generator's Name, Address and Telephone Number <br />r <br />. TrO UA 1-r=LITY <br />161.7 1 CALIFCRIaA ST <br />STOMMI, CA 95204- 6117 <br />(209) 948-6435 9/10/2013 <br />CU§MMERNUMBER, 6039652-002 GENERATOR'SREQt6TR MON <br />2A4DESCRIPTIONOFWASTE <br />2B. CONTAINERTYPE <br />2C. N <br />2D. VOLUME <br />UN$291 )tegulated Medial waste, ri.o s., <br />8 2t PGi1' <br />TBOS - 40 tial 'Cub (13io) (5.3 cu fit) <br />CONTAINAINERS <br />Cu Ft. <br />B � odi Regulated Medical waste, n.os,. <br />i+$4g - 37 Gal Tubb (Bio) (r1.9 cu tt) <br />Cu FL <br />B 2, 11 Regulated Medlal Waste, n ox, <br />T814 - 44 Gay Tubb (Hio) (5.9 ou ft) <br />(pW <br />P <br />Cu Ft <br />F" <br />UNMI Regulated Medical Waste, n o.s„ <br />TB21I. - 20 Gal Tub(Bio) (2.7 out ft) <br />6.27611' <br />Cu Ft <br />W <br />W <br />UN3291, Regulated Medici Waste, rms., <br />62,,PGII <br />TPIS - 24 (jai, cub (pat:h) (2.7 au !t) <br />Gu Ft. <br />8.2 PGII Regulated Mad,cat Waste, n c.s , <br />T!f15 - 20 Gal Tuffs (Chesno) (2.7 cU ft) <br />GU Ft. <br />8 � FGl`'Regu�ked Medical blasts, n as , <br />,. Bdi onstetas Cardboard Box (4.2 au ft) <br />Gu Ft <br />Waste, s., <br />1291; Regulated Medical no <br />Cu Ft <br />.p6amaaeutickil waste <br />iCu <br />Ft <br />31 Generator's Certification: 11 hereby declare that the contents of this consignment are fully and acxutately TOTALS I►' Cu FL <br />d§sonbed above by the proper shipping name, and are classified, packaged, marked and labsited/placarded, and <br />are In all respects m proper condition for transport according to applicable international and national governmental regulations" <br />I ( 0— <br />I ; Printed/iyped Meme Signature Data <br />&TIRANSPORTEF) I ADDRESS: Phoria #: (589W9-1121 <br />Stericycle, Inc. This is a The ugh ShiPmernt Appboable Permit Numbers <br />-�' <br />4135 Swift Ave <br />Q, <br />Hauler R,egl# 3400 <br />Ecevno,CA 93722 <br />a xz <br />TRANSPORTER CERTIFIGA�T,irQN: Receipt of medical waste as described above <br />prin07ype Name Signature Date 0 <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone # <br />Applicable Permit Numbers• <br />+�+ <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medloal waste as described above <br />Pdnt/Type Nano Signature pate <br />6. INTERMEDIATE HANDLER S I TRANSPORTER 3 ADDRESS: Phone # <br />Applicable Permit Numbers <br />o <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above. <br />P6ht/Type Name Signature Date <br />7. DNSCREPANCY INDICATION <br />yds @{�j �}�p 1�° <br />TMN*TMd „�„�„ CO erg. W h t4 . North Sal Lake, U B <br />[]18A. Deaigrieted Faculty: rl 613. Aitemate Facility: ® 30. Alternate Facility ❑ So, Alternate Factiky: <br />3bedcycle, Inc. lbi C fCta, trtC. cycle. Inc. S"1ajale, Inc. <br />036 W. Ave 90 N. ®Ana 1661 <br />, �Sittte Me 2716 E. 26th St; <br />u; <br />Fmeno.CA 22 North t3�ll telco. ur 8'4 (!5- 0114 HOMM CA SM Vernon, CA 9()068 <br />(659) 276-121 (soi)9313.1656fit) IUsS (323) 362.3000 <br />' MOST 83 T -26 <br />M <br />AUTOCLAVE <br />1— <br />TRE �ALIARTRerhfy tit t I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above Indicated waste in accordance with the requirement outlined In that authorization. <br />Pdrltffypa7ttirfine1 -0-2013 Signature Date <br />r <br />r_ <br />ORIGINAL <br />