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IjAvw <br />MEDICAL WASTE TRACKING FORM NUMBER N <br />00 <br />le 0 Sterityde' CASE OF EMERGENCY CONTACT' CHEMTREC 140-424 STA MANIFEST 001-10-MSTD <br />• e 'ftqo Aad-"na Route 9: 318 - 12 CUSTOMER NO. 21132 MDFROOB5VX <br />NMI <br />1. Generator's Name, Address and Telephone Number <br />ATTN: Pedro Gonzalez <br />S Vr= TRACY HiDSPITAL <br />1420 1. TRACY BLVD. <br />TRACY, CA 95376 <br />(209) 832-6032 7/19/2011 <br />CusroMe MUNUMn 607 56-002 f3 Rr4 saAtical• <br />2A. DESCRIPTION OF WASTE <br />213. CONTAINERTYPE <br />2C. NO. OF 20. VOLUME <br />UNMI. Repldated Medical Waste. nos., <br />6.2. 1`6111 <br />TB57 - 90 }sal "Pub (' o) (12 cu ft) <br />4001,1`11AIMERS <br />Cu Ft <br />6.2 11 Regulated Medich Waste. n os. <br />TB49 - 31 Gal Tub ( o) (9.9 Cu ft) <br />Cu Ft <br />M <br />Q <br />UI lld Regulated Medical Waste. n.o.s.. <br />6.2. PG <br />7814 - 44 Gal Tub (bio) (5.9 cu !t) <br />Cu Ft <br />Q <br />UNMI. RODUMed Medical Waste, n.os . <br />TB21 - 20 tial Tub (Bio) (2.7 cu ft) <br />6.2. PGII <br />Cu Ft <br />W <br />UNMI. Regulated Medical Waste. nos.. <br />62. PGH <br />T815 - 20 Gal Sub (Path) (2.7 cu ft) <br />tar FL— <br />IZ <br />JI <br />UNMI. Regulated Medical Waste. n.o.s.. <br />6.2. 13611 <br />TY15 - 20 Gal Tub (Ch o) (2.7 cu ft) <br />Cu Ft <br />UNMI. Regulated Medical Waste. nos.. <br />6.2. PG11 <br />Ft. <br />UNNSI Reoulated Medical Waste, n.o.s.. <br />6.2. PGII <br />Cu Ft. <br />'I Waal -ad <br />CM FL <br />3. tlexterator s Certification: "1 hereby declare that the contents of this consigninant are filly and accurately TQ TALS ® O � , Cu Ft <br />described above by the proper shipping name, and are classified, packaged, marked and labellaftlaceddled. and <br />are In all respects in }roper condition for transport nocordirlg to applk able Intefftational and national govemntental regulations' _ <br />Prin Name Signature Data 2 w <br />cc4. <br />TRANSPORTER t ADDRESS: Phoma s: ( 5 ) — <br />UA <br />Stericycle, Inc. This is a Thcough shipment Appkabjq permit N rs: <br />a <br />4135 hest Swift Ave. Hauler Reg# 3400 <br />1YJ <br />Fresno,Ca 93722 , <br />a i <br />TRANSPORTER C can a medw waste as described <br />w <br />PrimnW* Name Silptatore Qat® r <br />6. INTERMEDIATE HANDIER 2 / T PORTER 2 ADDRESS: Phone e: <br />Permit <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/fype Name Signature Date <br />s, I= <br />a <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Plane N. <br />4D ul <br />Applicable Parrllit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: ReeW of medical wage as described above. <br />PrintgW* Name Skirtature Do% <br />T. DISCREPANCY INDICATION <br />Trattsterred cordainem, eu R to : North Saft Lake, UT <br />e& Dewfinated Fecnhy: aa. Almnate Facility: W. Alternate Fnc &D. Aftrnaft Faculty: <br />$ <br />�! <br />Stem ycle Inc -Autodm SterIcycle Ino. Indnemdon StarIcycle Inc-AUtoda3ve Stericids Inc-Attotiave <br />2775 E 2M STREET <br />4135 W. StMFT AVE 90 NORTH 1100 VWST 1345 Drive Ste C <br />FRESNO.CA 93722 NORTH SALT LAKE Sten Leandro, CA 94577 VERNON. CA 90023 <br />(559) 5-1121 (90 f) 2311- 1555 (610) 562- 2177 (323) 362 - 3000 <br />w <br />Pli <br />AN N E U ! �A�as-.�a 36 TSki 1l1�lOST25 -26 <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept w-dreated medical wastes and that I have <br />a <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />JUL 19 2011 <br />PdnVtype Name signature Date <br />NMI <br />