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• MEDICAL WASTE TRACKING FORM NUMBER <br />•0.0 Stericyde, CASE OF EMERGENCYACT: CHEMTREC 1 -12400 STA MWFW 001•uloe-STD <br />®® Route J: 318 - 10 CUSTOMER NO, 21-M M01FROOMM <br />I. Generators Flame,:eas and Telephone Number <br />ATTNTN: Pedro Gonzalez <br />SVr=R TRACY HOSPITAL <br />1420 N. TRACY BLVD. <br />TRACY, CA 95375 <br />(209) 932-6032 7/26/2011 <br />Cr Numm 60701561-002 T e <br />2A. DESCRIPTION OF WASTE <br />28• CONTAINER TYPE <br />2C. NQ OF <br />20. VOLUME <br />UN3291, Regulated Medical Waste, nos., <br />T857 - 90 Gal Tub ( " o) (12 cu ft) <br />CONTAINERS <br />6.2, PGII <br />Cu Ft <br />UN3291.1tegukWMedzNs.. Waste, <br />TB49 - 37 Gal Tub (Bio) (4.9 cu tt) <br />6.2, PGII <br />Cu Ft. <br />UN3291RegutatidMedical Waft nos.. <br />TB14 - 44 Gal Tub M0 (5.9 Cu ft) <br />6.2, PGii <br />Cu Ft. <br />UN3291. Regulated Medical Waste, 0.os., <br />a . <br />Q <br />6.2, PGII <br />Cu Ft. <br />W <br />UN3291, Reguteted Medical Waste, n.e.s.. <br />T815 - 20 Gal Tub ( Fath) (2.7 cu tt) <br />6.2, PGD <br />Cu Ft. <br />W <br />(5 <br />U2,PPGli Regulated Medical no.s., <br />6 <br />TY15 - 20 Gal Tub (C o) (2.7 cu f <br />CM F. <br />UN3291, Regulated Medical Waste. a.os.. <br />6.2, PGII <br />Cu Ft. <br />111113291. Regulated Medical Waste, nm., <br />6.2, PGII <br />Cu Ft. <br />Pharmaceutical tial <br />i <br />3. Ger+e~s Cerlltication: "I hereby declare that the contends of this consignment are fully and wraUrily TOTALS ► NOtQ;—Cu FL <br />above by the proper shipping n erne, and are clusilled, packaged. nuirload and Iled/placsrdsd, and <br />are In all respects ht proper �ttdiilOn for transport aCCOtding to eQ al and national govt m regvlatic, . <br />-j <br />-1 M 4 `! <br />Pdrtedlt Name Signaturea <br />cc <br />4. TRANSPORTER I ADDRESS: Phone n: <br />Stericycle, Ina. is is a Through Shipment <br />4135 Vwt Swift Ave.Ap HauleFernr Re' Nur� ra: <br />gP 3400 <br />CR <br />rre3no,Ca 93722 <br />am <br />TRANSPORTS FIC . Recelpt of mems al yeasts as <br />Pdrt/Type Name Suture Date <br />S. INTERMEDIATE FIANDLER / TRANSPORTER 2 ADDRESS: Phone 0: <br />ellN <br />App1 Permit Numbers: <br />HANDLER /TRANSPORTER CERTIFICATION: of medical waste as above. <br />Prinif Nam ype Signature Dasa <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone e: <br />Applicable PemtEt Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waft as clescitbed above. <br />PdrrVType Narra Signature Date <br />7. DISCREPANCY INDICATION <br />Transtelrefi eblltatners, CU R to : North Salt Lake, UT <br />® 8A Facility: 88. Alternate Facility: 1C. Alternate Fa hlty: !W. FaciIlly: <br />SWrk:Vde Inc-Aubadave Steedwde Ina Indner0m Steticyde Inc Aubsdave Stledeyde Inc-Autodave <br />E 26TH STREET <br />4 <br />4135 W. SWIFT AVE 90 NORTH i 100 WEST 1345 6eoiittie Drive Ste C 2776 <br />a � <br />FRESNO.CA 93722 NORTH SALT LAKE CITY, UT San Leandro, CA 94377 VERNON, CA 90023 <br />r` <br />(559) 275 - 1121 (801) 936- 1655 (610) 562 - 2177 (323) 362 - 3000 <br />TSIOST22 3A -448 -JA -38 TS31frSIOST29 TSRM 26 <br />a <br />TREATMENT FACILITY: I certify that 1 have been authorized by the appg de state agency to accept untreated medical wastes and that I have <br />H <br />received the above indicated wastes in accordance With the requirement outlined in that authorization. <br />PdnVtWm Name Signature Date <br />ee328 <br />