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11/12/2010 14:19 2092394 BUSINESS OFFIC PAGE 25 <br /> %;MrM.rVrjpA 1vur4imcm <br /> Storkyde- IN CASE Of EMERGENCY <br /> CONTACT:CH.EMTREC I.B00-424 STANDARD MANI FEs-r'Gomo-oe-s-ro <br /> are!'660 P"nmctbpP&6pIiLR0&dn9I1L1L' <br /> vouw I ; ial. .. 20 MDM009 M_ <br /> I Lo%n rfm <br /> 19 Generator's Name,Address and Telephone NU <br /> 1TN: Cathy/Maxine111011, * <br /> MA CA CARE & r4ra%q III-1111HIM <br /> AT '. <br /> STRUIrl '�!i III)( <br /> 410 E;ASTWOOD AVE <br /> KhVW,CA, CA 95336- 3167 ACCOUNT 4: cAj594!7-uu2 <br /> .Manteca Core 8 Reh&--'---� <br /> SERVICE DA rE: 5/20/1A 11;04:00 AN 19-1222 5/20/201( <br /> WIVER 10; RPI . I <br /> Cuwromm INUM811P 60J' 9477-002 SHIPPIW Bmay.i: ffVd§PR? <br /> 2A,DESCRIPTION OF WASTE ig, TOTAL COLLECTED, b 20. NO,OF 2D, VOLUME <br /> UN3291,Regulated Medical Waste,n.o.s.. T11157 — 90 Ga TOTAL UMME: 29,SW CU IT CONTAINERS6.2,PGII, Cu Ft <br /> U 291;'RequWted Medical Waste,n.o.s., T949 OM)154 TBA ODAO166 M14 OOAI*1156 <br /> N3 .37 14 <br /> 6.2,PGII '�4 ON157 T814 DOAD158 TE114 Cu Ft <br /> UN3201 RegulAted Medical Waste,n.a.a., T1914 44 G4 uF 57 <br /> 6.2,PGII L I VERy DtI0T-i-­rqqWft Qu Ft <br /> UNS291 Regulated Medical n.u.s., ITB21_ 20 '01 TOTAL DELI <br /> 6.2,Pali Cu Pt <br /> 4 UN3291,Regulated Medical Waste,n.o.s., T815 20 e. TWE <br /> P 6.2,PGII OTY Cu Ft <br /> UN3291,Regulated Medical Waste,n.o.s.. <br /> 6.2,1`611 TrIS 20 is T814 44 61 Tul)(111 fo.). CT 12.7 lb ? Cu Ft <br /> UN3291,Regulated Medical Waste,n.o,s,. <br /> 6.2,Pell Cu Ft <br /> UN3291 <br /> 6.2.PGII <br /> ReguMeil Medical Waste, CRIBI PARKA, MX U -Cu Pt <br /> FREaMy. Wftkl <br /> OT P I CKIF. sY9110 Cu F1 <br /> CUSTOMER SERVICE: <br /> 3.Generator's Certification:"I hereby declare that the cons Th" you for choosing Slericycle <br /> deacribod above by the proper shipping mama,and are clam nd Cu Ft <br /> are In all respects In proper condition for transport a=rclinj into!r lations" <br /> XPri2tggR!Ld Name <br /> 4.TRANSPORTER 1 ADDRESS: Phone 4: 059) 275 0 <br /> StAearicycle, Inc. Applicable Permit Numbers: <br /> rZ <br /> .35 t S <br /> Weswift Ave- <br /> IL 41 _h19 Igr a '��Uq� shipment <br /> Fre=,Ca 93722 <br /> TRANSPORTER ctmimcxnON: Receipt of medical waste as described above. <br /> PrinYrypa Name Signature Data <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: <br /> Phone 0: <br /> Applicable Permit Numbers; <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Reicelpt of medical waste as described above. <br /> Print/'0o Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of moftal waste as deacribed above. <br /> PrInt/Typo Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Trwitilifen*d ce It to- Neft ftK LaM, UT <br /> A,Designated Facnity! $131,Alternate F..Illty. F]OC.Aftwmte FacflWf. Six. <br /> S*kr*Im-AuWcW9 StIftWe k*"Kkweom 10* <br /> 4130 W.SVOT AVE 99NOM 111mve" 13 ova mb,__=I slab"ll: IM7157"MIM 9TRINT <br /> FIRMN04A 13722 NORT14 SALTLAKE MY.UT IM Lowdiro,CA SOM VERNION.CA 111110M <br /> (N73O)2 -OM (em)Wa-I-sw (510)W- 117111111 (11=1 362-3WO <br /> 7w.i.TSX*M T.WCGM CUM V lindnWOon Pen"110 1 ,1-115 <br /> TREATMENT FACILrrY. I certify that I have been authorized by the applicable state agency to accept untreated medical waster.,and that I have <br /> received the above indicated wastes In accordance with the requirement outlined in that authorization. <br /> Print/Type Name —Signature Date <br />