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— ---- --rte , <br />MEDICAL WASTE TRACKING FORM NUMBER <br />000 Stericyde' CASE OF EMERGENCY CONTACT,. CHEMTREC 1400-424 SGWOARD MAIRIFEST 001•1046SrD <br />°•• »' +' Route #: 318 - 10 CUSTOMER NO. 21132 MOFROOMM <br />1. Generator's Name, Address and Telephone Number <br />ATTN: Pedro Gonzalez <br />surrE t TRACY HOSPITAL <br />1420 V. TRACY BLVD. <br />TRACY, CA 95376 <br />II IIIIAlI1f111119001@I91�IB�11I <br />(209) 832-6032 <br />6070156-002 GINUMMS RECRIMAMON e <br />7/26/201] <br />3. Qenatata's Ceatltication: -1 hereby dere that the contents of this nt are folly and socurately TOTALS ► 1 . <br />dembed above by the proper shipping name. and are classillied, packaged, merited and labelledl*oarded. and ®® <br />are In all respects in proper condition for transport acoording U1 a and national govern <br />b—n 74 <br />'f <br />IN Name V h '� N SI tura . Dater <br />4. TRANSPORTER 1 ADDRESS: Phoma M: <br />�cc Stericycle, Ina. id This is a Through Shipment <br />0 4135 West Swift Ave.Al HauleVr RPe'eg9 u� ns3400 <br />Fresno,Ca 93722 <br />a TRANSPORTER CA ecsiot of medical waste as d <br />~ PdrdType Name signature <br />5. INTERMEDIATE HANDLER 2 / SPORTER 2 ADDRESS: <br />a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recoo of meetical waw as described above. <br />Pdattrype Name Souture <br />J <br />w <br />W <br />0. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />3 <br />s INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical wage as described above. <br />Prh V ype Name Silg'awre Date <br />7. DISCREPANCY INDICATION <br />10 Transferred containers, dr} R to : North Salt Lake, UT <br />Phone s: <br />Applicable Permit Numbers: <br />Date <br />Phone L". <br />Applicablo Permit Numbery <br />Ij IA. MI 88. Aaernoto Facility: u 15C. Alternate Feellty: fr: <br />® So. Alternate Fac <br />ft. <br />Wernema <br />todave Stett o Ino. Indo n CHAMBER INCINERATOR Stericyde Inc Autodave <br />FEAve.M95 V O Q k 7301 State Hwy 65 28161 KEITFI OR. <br />Fresno. CA 93725 ahuac. 7X 77514 LAKE FOREST, IL 60045 <br />(559) 8345880 (659) 2715 (409) 267-8206 (OW) 643.0240 <br />TSIOST22 M— W 0 , P PERMITAt MSV42M <br />—j�7-! <br />.e a 1 !Z <br />TREATMENT FACILITY. I Certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have <br />received the above Indicated wastes in accordance with the requirement outlined in that authorization. <br />Print/rypeMaa,a2 6 2011 Signature Dace <br />l0' <br />awl,l <br />RtRollIxIMM— 22411.2011 --- ORIGINAL <br />2A. OESCR1PTION OF WASTE <br />20. S14M 2 GaUan aC RTYPE <br />2C. NM OF <br />UN329i. Regulsim Medical Waste. nos.. <br />6.2. PGII <br />MM 1400caPhantessCoobim <br />CoNrAME <br />UNM6 . PPGIi Regulates Medial Wage n.os„ <br />S32PH 20aillonPhareasaCwAsigm <br />CUN3291. <br />Replated Medical Waste, n.o s., <br />S32PHA+ 8 Galton aC wide <br />Q <br />UN3291, Regnlaed Medical Waste, n&L, <br />TEWV—ww <br />6.2, PGII <br />W <br />1.111M. Regulated Medical Waste, a.os., <br />Z <br />W <br />6.2, PGII <br />S14 2 Collas SbalpaC <br />UN3291, Regulated Medical Waste, mos., <br />6.2, PGR <br />S22 116allonSim"C <br />UtN3291, Regulated Medical Waste, mos., <br />6.2.PGII <br />S32 SGRUOnSIM"Cordaonu <br />UN3291. Regulated Medical Waste, mos.. <br />52.PGIl <br />S32+ 8GallonSbarpsC eride <br />7/26/201] <br />3. Qenatata's Ceatltication: -1 hereby dere that the contents of this nt are folly and socurately TOTALS ► 1 . <br />dembed above by the proper shipping name. and are classillied, packaged, merited and labelledl*oarded. and ®® <br />are In all respects in proper condition for transport acoording U1 a and national govern <br />b—n 74 <br />'f <br />IN Name V h '� N SI tura . Dater <br />4. TRANSPORTER 1 ADDRESS: Phoma M: <br />�cc Stericycle, Ina. id This is a Through Shipment <br />0 4135 West Swift Ave.Al HauleVr RPe'eg9 u� ns3400 <br />Fresno,Ca 93722 <br />a TRANSPORTER CA ecsiot of medical waste as d <br />~ PdrdType Name signature <br />5. INTERMEDIATE HANDLER 2 / SPORTER 2 ADDRESS: <br />a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recoo of meetical waw as described above. <br />Pdattrype Name Souture <br />J <br />w <br />W <br />0. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />3 <br />s INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical wage as described above. <br />Prh V ype Name Silg'awre Date <br />7. DISCREPANCY INDICATION <br />10 Transferred containers, dr} R to : North Salt Lake, UT <br />Phone s: <br />Applicable Permit Numbers: <br />Date <br />Phone L". <br />Applicablo Permit Numbery <br />Ij IA. MI 88. Aaernoto Facility: u 15C. Alternate Feellty: fr: <br />® So. Alternate Fac <br />ft. <br />Wernema <br />todave Stett o Ino. Indo n CHAMBER INCINERATOR Stericyde Inc Autodave <br />FEAve.M95 V O Q k 7301 State Hwy 65 28161 KEITFI OR. <br />Fresno. CA 93725 ahuac. 7X 77514 LAKE FOREST, IL 60045 <br />(559) 8345880 (659) 2715 (409) 267-8206 (OW) 643.0240 <br />TSIOST22 M— W 0 , P PERMITAt MSV42M <br />—j�7-! <br />.e a 1 !Z <br />TREATMENT FACILITY. I Certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have <br />received the above Indicated wastes in accordance with the requirement outlined in that authorization. <br />Print/rypeMaa,a2 6 2011 Signature Dace <br />l0' <br />awl,l <br />RtRollIxIMM— 22411.2011 --- ORIGINAL <br />