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MEDICAL WASTE TRACKING FORM NUMBER <br />®i*® Sterkyde' CASE OF EMERGENCY CONTACT. CHEMfRgC t o FEST oor-tooesry <br />•• "'ft"`Mad"°` Route 4: 318 - 12 CtIS7OMERNo.2 MMDFROOB4TG <br />(;Ei Itt s <br />1. Generator's Nam, Address and Telephone Number <br />ATTN: Pedro Gonzalez <br />Stf TER TRACY HOSPITAL <br />1420 N. TRACY BLVD. <br />TRACY, CA 95376 <br />(209) 632-6032 <br />7/12/2011 <br />CUSTOM Niarahtn 6071 6-002 0Recant"M 11 <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINER TYPE <br />2C. NO. OF 2D. VOLUME <br />UN3291. Regulated Medical Waste. n o.s..CONTAINERS <br />62. Poll <br />TB57 — 90 Gal 'Pub (Rio) O) (12 cu ft) <br />Cu FL <br />6 ii Regidated Medical ' aoL' <br />T349 - 37 Gal TO (Edo) (4.9 cu ft} <br />Cu FL <br />® <br />8 Z F91 Regulated Medical wane n o.s . <br />TB14 - 44 Gal Tub t o} (S.9 cu tt) <br />q, Ft <br />Q <br />UN3291 R@PkW Medical Waste, rms.. <br />T821 — 20 Gal Tub( ' o) (2.7 cu ft) <br />cc <br />6.2. PGI I <br />Cdr FL <br />W <br />UN3291, Renalated Medical waste, nos,. <br />6.2,PGt <br />TB15 — 20 Gal Tub (Path) (2.7 cu ft) <br />IZ <br />Cu R. <br />UN3291, Replated Medical Waste, no s., <br />6.2, PMI <br />TY15 — 20 tial Tub (Chemo) (2.7 cu ft) <br />Cu Ft. <br />UN3291. Reputated Medical waste, ao s., <br />6.2. Poll <br />Cu Ft. <br />UN3291, Reptttated Medical waste, ao.&. <br />6.2, PGp <br />Cu FG <br />3. Generators CortiflcMlom 11 hereby declare that the contents of this consigment are fully and accurately TOTALS ® <br />Ab Cu Ft. <br />desatbed above by the Proper shipping nam, and are clessilled, padagod, nmkftd end label) ed, and <br />''UsEL <br />are in at respwM in proper condition for transport according to applicable International and national governmeniai reot at ns" <br />_ <br />IiPr<(.c (Al <br />-Signature <br />Date <br />4. TRANSPORTER 1 ADDRESS: <br />Phone e: (559)275-1121 <br />559) - <br />Stericycle, Inc. Th is is a Through Shipment <br />Stericycle, <br />AppurablePermttNunnbers: <br />r <br />4135 West Swift Ave. <br />.hauler Reg# 3400 <br />N <br />Fresno,Ca 93722 <br />Q <br />TRANSPORTE FIC TZOW Receipt of medical waste as <br />~ <br />Prfntttype Name Signature �'' <br />Date <br />6. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: <br />Phone t <br />e Perrrht Nhunbere: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of waste as described above. <br />Prinveype Nana Signature <br />Date <br />of <br />& INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone e: <br />Applicable Rermt Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of ffmcical waste as described above. <br />PrintiglAm Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />Transferred containers, cu It to : North Salt Lake, UT <br />BA Ffttty: 0 08. Aternav FwUbr. 8C. Aftnnb FacBtty <br />80. Alternate FacBity: <br />Sterttyyde Inc -AUtodsve StOdC de Ina Indn6 a Inc-Atttadave <br />Ste C <br />Sbe fa Eric-Autadave <br />2775 E 28TH STREET <br />a <br />4135 W. SWFT AVE 90 NORTH 1100 1345 OAIBite Drive <br />U. <br />FRESNO,CA 93722 NOM SALT LAKE CITY. UT Son Leandro. CA 94677 <br />VERNON. CA 90023 <br />(559) 275 - 1121 (SDI) 936 - ) 556 (510) 562- 2177 <br />(323) 362- 3000 <br />TS10=2 3A -44&A-36 TWUrStOST25 <br />TSIOST 26 <br />W <br />AN-INIF ORT <br />EATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated <br />received the above indicated wastes in accordance With the requirement outlined in that authorization. <br />nvidical wastes and that I have <br />PrinveypeNarri��� 9 Zd�t <br />si�hatureDoe <br />(;Ei Itt s <br />