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MEDICAL WASTE TRACKING FORM NUMBER <br /> o ® StericyCle• IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800.424-9300 STANDARD MANIFEST 001-10-WSTD <br /> P`iwiingPmpl&QK4task, Route #; 126 — 8 CUSTOMER NO.21132 M17FROOHOX9 <br /> 1.Generator's Neime,Address and Telephone Number <br /> ATTNsMaurice Allen <br /> RXN/RAISER STOCKTON MOB 11 11 1111 11!!!!!! 1 iii 1111 I!!!! 111111€€€ 111 I1 1111t# It <br /> 7373 NEST LIS <br /> STOCI{'`I'OIS, CA 95210— 3377 <br /> (209) 476-5152 4/8/2016 <br /> CUSTOMER NUMBER 6'116492-750 GENERATOR'S REGISTRATION# <br /> 2A.DESCRIPTION OP WASTE 2B• CONTAINERTYPE 20. NO.OF 2D. VOLUME <br /> UN3291 Regulated Medical Waste,n o.s, CONTAINERS <br /> 62,PGII KRR2 — Bio Systems Wheeled Rack (58.9 CUFT) CU Ft. <br /> 64 PGI Regulated Medleal Waste,n os., gRR3 — Bio Systems Wheeled Rack (53.5 CUFT) <br /> Cu Ft. <br /> Qit 8 232�� Cu Ft,Regulated Medl0l!Waste,n,o.s., <br /> UN3291 Rogutated Medlcai Waste,n.o s., s <br /> 6.2,PGI AKCu Ft. <br /> W UN3291 Regulated Medical wa*,n.os., <br /> 1111 111 <br /> 6.2,P3I1 Cu Ft <br /> UN3291 Regulated Medical Waste,n.o.s., �/^i <br /> 6.2,1`0I1 p "" Cu Ft <br /> UN3291Regulated Medical Waste,n.o s., <br /> 6.2,PGII Cu Ft. <br /> UN362,PGII 91Regulated Medlgi Waste,n.o.s, RSB _ Biosystems Cardboard Box (4.2 cu ft) <br /> Cu Ft. <br /> UN3291 Regulated Medical Waste,n.os., <br /> 62,PGIi <br /> Cu Ft <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS ® Cu FG <br /> de d above by the proper shipping name,and are classified,paftged,marked and iabelledfplacard <br /> a I spects In props IUon for transport acro ing to applic bie International and national gover mental r gulations" <br /> AIPrin ped Name ate �Y <br /> 4. PORTER 1 ADDRESS: Phone B: (866)7$- <br /> Sterieyele, Inc. This is a Through Shipment Applicable Permit Numbers <br /> 4135 A <br /> g N Fresno,CA 93722TI <br /> a TRANSPORTER C TIFIC N:�t ei of m i waste as descdib <br /> PrinVlypei Name Signature �+1:J �-/V <br /> Date <br /> 6.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone if: <br /> N <br /> Applicable Permit Numbers. <br /> �+ INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medal waste as described above. <br /> PrinIt yps Name Signature Date <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS' Phone N: <br /> E S Applicable Permit Numbers. <br /> x <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> — PrinMpe Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> ❑ <br /> 8A.Designated Facility. 88.Alternate Fact ny ®8C.Alternate Faculty. <br /> ly <br /> Sterlcycle,fnc. cycle,lnc. Stericycle,Inc. •,,�•..--E <br /> i 4185 W.Swift Ave 9 N.Foxboro Drive 1651 Shelton Drive <br /> Fresno,CA 83722 No Salt Lake,LIT 94054 Hollister,CA 85023 APR 2 8 2016 <br /> (868)783-7422 (866)783-7422 (866)783-7422 <br /> wg TS/0ST22 SA-448-JA-38 TSIOST 83 (Rd <br /> M~ 1 incinerated <br /> TREATMENT FACILITY:I certify that I have been authorized by the applicable state agencystcal ated medic i wastes and that I have <br /> I— received the above indicated wastes In accordance with the requirement ouUln d to that au n <br /> PrinVType Name Signature <br /> Date <br /> Transferred conta n , 1 cu ft to <br /> tltarkyWs,plc. <br /> lsal+nea CayN,171ht8 6SLtft16 <br /> Ch®d 6 r maim <br /> ORIGINAL <br /> i <br />