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as Stericycle' .e ►ro.a.aynW, AM*A-E OF EMERGENC CO CT: CK[ REC 1-WC,,234& STANDARD MANIFEST 001.10 -06 -STD Route -MDFR008QAP. I. Generator's Name, Address and Telephone Number ATTN. Carla Vallettt/pro]ect M111111 Il II i1 !1 1! !1 BIO/ST DOES IMMED CARE/OCCHLTH 1801 E. MARCH LANE BLDG 470D/480D STOCKTON, CA 95210 (209) 467-6395 12/2/2009 6062904-003 CUSTOMER NUMBER GENERATOR's REGIsTRAnoN# 2A. DESCRIPTION OF WASTE • 2B. CONTAINERTYPE 2C. NO. OF 20. VOLUME REGULATED MEDICALd&F%#o.s.,6.2,._ -.BS02/RS02 - 2 Gal Sharps -Reusable -(0 -3 -cu -ft) --- - "- -CONTAINERS------ UN 3291, PG II Cu Ft REGULATED MEDICALM ffi;ja.s.,6.2, WYA303-3 Gal Sharpe Reusable (0.4 Cu ft) UN 3291, PG II Cu Ft CC REGULATED MEDICALMIEW.s.,6.2, BSOO/RSOO-0 Gal 9 drpo ReUgable ( .1 Cu ft) O UN 3291, PG II Cu Ft Q REGULATED MEOICAIGIrS�o.s.,6.2, CC UN 3291, PG II Cu Ft W REGULATED MEDICAL WASTE, n.o.s.,6.2, TBUZ- Gal Reusable cu W UN 3291, PG 11 Cu Ft REGULATED MEDICAL WASTE, n.o.s..6.2, UN 3291, PG 11 Cu Ft REGULATED MEDICAL WASTE, n.o.s..6.2, $ Q Q f P 3 i ,q 3 eT UN x ` CAA 1 Cu Ft REGULATED MEDICAL #&yE, Vs., KR65 - Wheeled Rack (59.4 cu ft) UN 3291, PG II Cu Ft Regulated Medical tRt - Bio systems Cart or Box ( au ft) 4.3 Cu Ft 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS /" 2 $ . G Cu Ft. described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulation " Printed/- ed Name r Signature ate 'Z Z 4. TRANSPORTER tPhone #: S�&RL�iZ�ycle, Inc. >" 4135 West Swift Ave. Applicable Permit Numbers: IM a Freano, ICa 93722 This is a hrvug shipment kn a Q TRANSPORTER CERTIFICATION: Recaipt of medical waste as/scribedabove. ~ �' ��'f""` I— 1:_® Print/Type Name SignatureDate 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #: fl¢ S w� Applicable Permit Numbers: Z � INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Printrrype Name Signature Date 4 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #: ¢ 5 L Applicable Permit Numbers: J m Z Q INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Fzea - Print/Type Name Signature Date 7. DISCREPANCY INDICATION i Trans% containers, CU fl to : North Salt Lake, UT y aA. Designated Facility: I A 88. Alternate Facility: 8C, Alternate Facility: 8D. Alternate Facility: STERICYCLE INC STERICYCLE INC STERICYCLE INC STERICYCLE INC J 4135 W. SWIFT AVE 90 NORTH 1100 WEST 9053 NORRIS AVE. 2775 E 26TH STREET FRESNO,CA 93722 NORTH SALT LAKE CITY, UT SUN VALLEY, CA 91352 VERNON, CA 90023 Iq (659) 276.0994 (801) 936.1666 (818) 504 - 6937 13231362- 3000 I-- TS3 i , TS/OST25 TWOST22 Class V Indneration Pem 9 91- P-6, P-115 g Pili QUE WILSON TREATMENT FACILITY: I certify that 1 have been authorized by the applicable state agency SD accept untreated medical wastes and that I have received the above indicated wastes ib ffr fue�wii h the requirement outlined in that authorization. �` {{jj I3SUignature Date Print/Type Name mriis An Q V L V R-. J