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<br /> NIEDECALtVA! TETIRACKING FORM tJUA4r`'
<br /> *qtericyc eR IN CASE OF EMERGENCY CONTACT:CHEMTREC'1-000-424-9300 STANDARD MANIFEST 001-14ou-STO
<br /> ° .i ROUte : 124 — 7 CUSTOMER NO.21132 MDr,ROC17vjNJ5
<br /> 1,Generator's Name,Address and Telephone Number %
<br /> ATTWasephine YoKingluo 1I I
<br /> OOH QUAIL LAKE-CFIATEAU HSPITL
<br /> 1221 ROSEIVKRIE LN
<br /> STOCKTON, CA 95207-8703
<br /> 209)477-26664 9
<br /> CUSTDMERNUM13ER 615620,5-001 GeNERATowsRiewsmmoNif
<br /> 2A.DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C. NO.OF 20. VOLE.tE
<br /> 2,PelRegulated Medical Waste,n.us., CONTAINERS
<br /> 6. l MO4-' 28 Gal Tub Bio 3-7 au ft
<br /> S,23PGi Regulated Medical waste,l.o,s., $_37 Gia!Tub(Blo) (4-9 eu ft)
<br /> rr;
<br /> ® 82,P II Regulated Medical waste,mos., fi 14 44 Gal Tub(Blo){5.9 cu ftp,.,
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<br /> UN3291,
<br /> 2329,Regulated Medical Waste,o.o.s:, )�`%—L- . 1�`�..._..._J2o Gal' ub(2,70UFT
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<br /> W UN3291,Regulated Medical Waste,n.o.s,,
<br /> z 6.2,PGII
<br /> UN3291Regulated Medical Waste,no-s.,
<br /> 6.2,PGII WB43-( WJP43-( C"A Gal Tub(53CUFTI Cm
<br /> fi 2,PGII Regulated Medical Waste,nos., KR Biosystems Cardboard Box 4.3 cu ft) c
<br /> 6 23291,Regulated Medical Waste,n.o.s.,
<br /> Cr
<br /> UN3291.Regulated Medical Waste,rias.,
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<br /> s.2,PGII cry
<br /> 3*Generaws Certification:It hereby declare that the contents of this consignment are fully and accurately TOTALS 1. C„
<br /> d ve by the proper shipping name,and are classified, aekaged,marked and labelled/placarded,and
<br /> e all re ecis in prop ditlon for transport according t p I Is trltemational and zatflonau_MermnM�"alegulation :'P4n typed Na tQafe i
<br /> a TR ORTER 1 ADDRESS: Y—
<br /> Steriaycle, Inc. ® Thishrough Shipment Applicable Permit Numbers:
<br /> 4135 W.84ft Ave Hauler Reg#3400
<br /> 2 Fresna,Ce4 93722
<br /> !
<br /> 'z TRANSP®RTECERTIFICATION:Receipt of medicei waste as describe
<br /> Pdnt/Type Name .i Sigrtaiure Date f
<br /> S.INTERMEDIATE HANDL R 2/ RANSPORTER 2 ADDRESS: Phone#:
<br /> Applicable Parmit Numbers:
<br /> 1 sFy INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medleal waste as described above.
<br /> a� x
<br /> E R PrinVType Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone sI:
<br /> irs Applicable Permit Numbers:
<br /> ja�
<br /> r-a z INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION:Receipt of medical wasie as described above.
<br /> 's PdritlType Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> i
<br /> 8A.%Tr Fa�ili�y: 8S. s Fac1rlty: SC.Altemate FaclMr. ®aQ.Atinmate Faculty:
<br /> S18riCyC1a lnG.(Autoclave) Stefi (crpj lnc.(Iricinere tQr) Slericycle,Inc.(Autoclave) CQYanta Mallon.Inc
<br /> 41315 W,80tAka 90 N.FtYbOro Drl" 1551 Shelton Driva 4660 Brooldalce Road E.E
<br /> Qno,CA 93722 North Salt Lake,UT 84054 Hollister,CA 85023 Brooks,OP 97305
<br /> 'L (869)789-7422 (801)931GA 171 f888)733-7422 £5053353 0880 .
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<br /> `JN SIOST-22 3A�8f.1A-35 TSfOST-83 Permlt#364
<br /> $ DAIE ANNE OFTTIZ
<br /> TREATMENT FtKCILf q-f�iify that I have been authorized by the applicable state agency to accept untreated medical wastes and that l have
<br /> t— received the&)Lao Inc�t:a i wastes in accordance with the requirement outilned in that authorization.
<br /> I PritiVrype Name Date
<br /> TrAnsf@rr@d txtrttalttl�rs, tit 13 tt9 _N.321111 Laitle,UT
<br /> l - -
<br /> ���� ----- __--_ t?RIGINAL
<br />
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