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11/12/2010 14:19 209239 BUSINESS OFFI PAGE 26
<br /> ��&rohw+.,ree,�,e •• •tasF oC I:A4EgGIENt:Y Cf3t�r1'ACT:CHE C g' e.os,�;r.•t�1q�ISYLNCI"FGlR ,
<br /> Route .'if: 3.Q1 .- 22
<br /> 1,Genermor'S Name,Address and Telephone Number
<br /> SERVICE REtEIPi
<br /> AWN: Cathy/MaxineKAWn9CA ACCOUNT a; 6059477-002
<br /> CPIM € Fzma Manteca Care 8 Rehab
<br /> 410 zAsTwOOD AVE StRVICF DATE; 91161'10 1 :05 GM
<br /> DRIUER 10: RBi
<br /> CA 953,31S•- 3167
<br /> SHIPPING DOCUof RI_.Nni)w?
<br /> TOTAL Cd_LFCTEO: 4
<br /> CUSTOtTR Nuampri DESCRIPTION REtitMA roN S ®� TOTAL IDLUNE, 13,ion CU FT7-
<br /> 2A.DESCRtPT
<br /> N OF WASTE 28, tyiA016V Ria OOA016Z RRIa 1plA
<br /> 6 2329 ;Regulated Medical Weste,n,o,s.; r CANTfiINER TYPE 0OA01GO T814 i)170 RR 1a
<br /> ..
<br /> T1357 - 90 Pial Tubi '(tie) (22 cu ft)
<br /> UN3291 Regulated Medicdl Waste,n.D,r. VOL
<br /> 6.2,PGtI Tim9 - -7T Gat `,Cub (DiQI �(4.S cm ft) SUiNARY(Cont Type) ON CF
<br /> pC UN3291 Regulated Medical Waste,n,o,s..
<br /> C7 6.2,P1311 T91.4 „ 4E4 Gal ,��($f.0) (�.9 CU Ta la Gal (Phare), 0 Tare R 3 7.200
<br /> F- UN3291,Regulated Medical Waste,n.o.s_, ) Ifi74 44 Gal Tub(OiD), CT 12.7 1 5,900
<br /> 6.2,PGR TBZ1 - 20 C.ak T"b(8io) (2_7 cls ft)
<br /> W �IIVFAVI�l11MENTt;UN3291,Regulated Medical Waste,n,o,s., PDFR00*7
<br /> W
<br /> 6,2,PGII
<br /> T815 — 20 0.81 Tub (1Patrh) (2.7 tm tt) TOTAL OELIVFREO'ITEMS:•1•
<br /> 0 UN3291ROQUlatad MediNI Waste,n.o,s.,
<br /> 6.2,PGli
<br /> 20 041 Tub ( o) (2.7 cu. ft) TYPE OTV
<br /> UN3291,Regufated Medical Waste,n.o.s:,'
<br /> 6,2,PGII TB14 44 Gal Tub(Bio), CT 12,7 Ib i
<br /> UN3291,•Regulated Medical Wasto.n,D,s.,
<br /> 6.2,PGII
<br /> DRIVER; Blythe, yRusaII
<br /> ERAT�F
<br /> tors OsriUflcadon;°I hereby declare that the contents of this oonelgnm®n1 are fully and accurately NFE�1tT�PEIp(VC)p g/23!10 u•1
<br /> above by the proper shipping name,and ata clasaifled,packaged,marked and labelled/placarded,and CUSTOMER SERVICE; u:l
<br /> spects in proper condition for transport according to applleaal International and national
<br /> ,w 90mmmantalfegulath Thank you for choosing Stericycle
<br /> edfryped Narhe �
<br /> RTER 1 ADDRESS:
<br /> 51 lure �'�✓ '•
<br /> S,tericycl ;r Inc. Phon,
<br /> 4135 t Swift Ave. .ApplicalEAR KRE- -
<br /> FceSMI Ca 937""2 Thiat in a Through S
<br /> �u 9 �. etRt
<br /> CIERTER.CIERTiFICATIot4 e ,_ of medical wast®ae described abel
<br /> em® -
<br /> Signature
<br /> 5.INTERMEDIATE HANDLER 2/TRA R 2 ADDRESS: ;i`r Date
<br /> E
<br /> .:Phone 4:
<br /> Appllcable Permit Numbers:
<br /> l INTERMEDIATE HANDIER/TRANSPORTER CERTIFICATION- ROOatpt of medical waste as desodbod above.
<br /> PrinNTWm Name
<br /> Signature Date
<br /> 7INTERMEDIATE
<br /> TE HANDLER 3/TRANSPORTER 3 ADDRESS:
<br /> Phond a:
<br /> HANDLER/TRANSPO a CERTIFICATION:Receipt medk�t waste as deecnbed above, Appacablo Permit Numbatg:
<br /> Print/Type Name
<br /> Signature
<br /> 7.DISCREPANCY INDICATION Date
<br /> SM&D�Wgnstod Feenity: t ft� : C
<br /> OC"
<br /> 0e.Altgntara Facility: ®eC. ate FacMhy:
<br /> 8D.Altemate Feetlhy;
<br /> T*3 1,T21018175 TIVOSM 4:24
<br /> Ino-A ino-I
<br /> nClAwillium
<br /> 4136 W.SWFT AVIz :{� 1 t� T iM' C ftftyde Irtc-
<br /> (SSt#)2 g' VOPOM.CA W=
<br /> +N p e RTM T Com.UT ( �j y� :T'?6 I .
<br /> 1TREATMENT FACILM:I certify that I have been authorized by the applicable state agency to accept untreated rnedi
<br /> received the above indicated wastes In accordance with the requirement outlined In that authorization_ cel wastes and that t have
<br /> Print/Type Name
<br /> Signature Data ,
<br />
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