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e4 'Stericycle' - MEDICAL WASTE TRACKING FORM NUMBER OF EMERGENCY CONTACT: CHEMTREC 1 800.234-0 STANDARD MANIFEST Cot-io-os-STO Route Ai: 313 - 11 MOERO07GQS 1- Generator's Name, Address and Telephone Number ATTN: Estela Halliday KAISER MANTECA 1721 A YOSEMITE 6-68-5321-00603 MANTECAr CA 95337 (809) 476-3593 '- 17 1N 09 .+a....+cn INUM M V V d O't 4 0- v u Z GENERATOR'S REGISTRATION # PERU IMEHAM 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO. OF 2D. VOLUME REGULATED MEDICAL WASTE, n.o.s.,6.2, SiE:RICYCLE INC CONTMRVS 4135 W. SWFT AVE 90 NORTH 1100 WEST UN 3291, PG it TB57 go Gal Tub (trio) (12 cu ft) tL Cu Ft. REGULATED MEDICAL WASTE, 12.o.s.,6.2, UN 3291, PG 11 Tg49 _ 37 Gal Tub {ria} {4.9 CU tt} i- (539) 275 - OM (801) 936 - INS (818) 504 - 6937 (323) 362 - 3000 Cu Ft. REGULATED MEDICAL WASTE, n.o.s.,6.2, UN 3291, PG TH19 -144 Gdl Tub {Bio} {5. Cu!tT 11 W Cu Ft. REGULATED MEDICAL WASTE, n.os.,6.2, 7132 - 20 Gal Tub(Bio) (2.7 cu ft) Pnnt/rype Name Signature UN 3291, PG II Date Cu Ft. REGULATED MEDICAL WASTE, n.o.s.,6.2, UN 3291, PG 11 TB15 - 20 Gal Tub (Path} (2. T cu ft) Cu Ft. REGULATED MEDICAL WASTE, n.o.s ;6.2, UN 3291, PG n , TY15 - 20 Gal Tub (Chemo) (2.7 cu ft) Cu Ft. REGULATED MEDICAL WASTE, n.o.s.,6.2, UN 3291, PG II Cu Ft. REGULATED MEDICAL WASTE, rl.os.,6.2, UN 3291, PG it Cu Ft. Pharmaceutical vaate CuFt. 3. Generator's Certification- "I hereby declare that the Contents of this consignment are fully and accurately TOTALS 110- Arlo Cu FL described above by the nrnner ehirx.3— nn . n..A — u-. ar_ a .. - .. ......e....a .._,e , ._ Bra in all respects in proper condition for transport according to applicable international and national governmental regulates." JJAI Printed/Typed Name M C41 of IM 4. TRANSPORTER i ADDRESS: } W Stericycle, Inc. a ® 4135 first Swift Ave. 9 0. E'resno a 937 ME a TRANSPORT CE t rr A-Acr-50 waste as described shipment: ~ Print/Type Name Signature Is 5. INTERMEDIATNtiLER 21TRANSPORTER 2 ADDRESS: s� INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/rype Name Signature Date Phone#: (559) 275 - 0994 Applicable Permit Numbers: Date I 411 "v= Phone IF , Applicable Permit Numbers: Date M 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: cc W - 4 M Applicable Permit Numbers: ZZ 49 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. PrinUiype Name Signature Date 7. DIS,CrREPANCY INDICATION Tminfeirrad cantaimm, eu 1t to EM �.. .r.V r; r ��• 1110 - [VU Designated Facility: 88. Alternate Facility: SC, Alternate Facility: Ito, Alternate Facility: STERICYCLE INC STERICYCLE INC ST'ERICYCLE INC SiE:RICYCLE INC a 4135 W. SWFT AVE 90 NORTH 1100 WEST 9053 NORRIS AVE. 2775 E 26TH STREET tL FRESNO.CA 93722 NORTH SALT LAKE CITY. UT SUN VALLEY, CA 91352 VERNON, CA 90023 i- (539) 275 - OM (801) 936 - INS (818) 504 - 6937 (323) 362 - 3000 1531, TWOST25 TSX)ST22 Gass V Incineration Permit# 91- P-6, P-1 is W TREATMENT FACILITY: FI have been authorized by the appli received the above ' ted acrry� h the requirement Di VJ lye to a ntreated medical wa a and t�lhat I have 2 2009 Pnnt/rype Name Signature Date EM �.. .r.V r; r ��• 1110 -