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MEDICAL WASTE TRACKING FORM NUMBER 0 e 0 Stericycle, WASE OF EMERGENCY CONTACT.CHEMTREC 11-800-4241 STANDARD MANIFEST 001.10-06-STD V blaute -0; 317 – 6 CUSTOMER NO.21132 FIDFROMTRZ 1.Generator's Name,Address and Telephone Number ATTN:ROBERTA PEARCE-FACILITY 9,7140 11449DIATE CARE LAB 1801 E PMR01 LN STE D4110 209-954-313 STOCKTON, CA 95210- 6677 (209) 954-3131 6/12/2013 CUSTOMER NumueR (5068398-001 GENERArows REGISTRAMN 2A.DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C.NO.OF 2D. VOLUME UN3291 Regulated Medical Waste,n o S., TBOS – 40 Gal Tub (Bio) (5.3 cia -Et) CONTAINERS 6.2,Poll Cu Ft. UN3291 Regulated Medical Waste,ri.o.s., TU49 – :37 Gal Tub (Bio) (4.9 cu 1:t#6,2,P611 • Cu Ft. CC 3291 NURegulated Medical Waste,n os., TB14 - 44 Gal TUb(Bio) (5.9 CU ft) & 6.2.PG11 Cu Ft. UN3291.Regulated Medical Waste,n.o.s., TH21 – 20 Gail Tub(Bio) (2-7 cu ft) 6.2,PGII IIE Cu Ft W UN3291 Regulated Medical Waste,n.o.s., TPIS – 20 Gal Tub (Pat33) (2.7 cu ft) Z 6.2,PGI I Cu Ft UJI UN3291 6.2.PW Regulated Medical Waste,n.o.s., =5 – 20 Gal Tub Jcbeno) 12.7 cu ft) Cu Ft UN3291 Regulated Medical Waste,n.os., MB – Blow 6.2.PQIl .1stew Cardboard Box (4.2 ca ft-) Cu Ft UN3291 Regulated Medical Waste,n.os., 6.2,PGI i Cu Ft ?harmalCautical Waste--- - Cu Ft. TALS 110 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately Cu Ft. described above by the proper shipping name,and are classified,packaged,marked sfidItUALed/placarded,and areft all respects In proper con ion to;,tra port according to applicable international Lard net- ,at govemental re,uI t' ons. Pi )IadMog lure ped Name g Date /17 AZR_WSPORTER 1 ADDRESS: —DPhone#: (559)2178-1121 EjTtds is 0a . h shipmek/ Applicable Permit Numbers: U TRANSPORT �l CA I of medical waste as describ above. pt of medical Print/Type Nam M IM&MM —SIgnatur, Date 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone N: Applicable Permit Numbers: INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Raceip of medical waste as d bad above. PrInMpe Name Slgnaturs7 Date 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#: Applicable Permit Numbers: INTER EDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. Fri pa paNarno Signature Date 7.D CREPANCY INDICATION Transtermd-containers,-cu ft to: Noft Salt Lake.UT GA.Designated Facility; 813.Alternate Facility: 8C.Alternate Facility. go.Altomato Facility: Stericycle,Inc, Stericycle,Inc. Stedcyde,Inc. Inc. AUTOCLAVE tqEXM0AMffLftR-Tj1&rtVitha I have been authorized by the applicable state agency to accept untreated medical wastes and that I have I.- recelved the above Indicated wastes in accordance with Ithe requirement outlined in that authorization. PrIn"K12lua— —signature Date P