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MEDICAL WATM TRACKING FORM NUMBER <br />01001,110 <br />` ®® Stericytte' <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-93M <br />Anert-a A. 'tfll - 4 CUSTOMER NO. 21132 <br />STANDARD MANIFEST 001.1046-STO <br />,,■ 1tt: <br />ELA-77, ORIGINAL <br />1. Generator's Name, Address and Telephone Number <br />AWN: I } <br />GOLDIM LIVItIG HYPANA - 569 <br />4545 SHLrLLEY COURT <br />STOCK B, CA 95207 <br />0 77-0271 5/16/2012 <br />Cussomm Num"A _ GetERAAtoa s RgctsrnAzm i <br />2A. DESCRIPTION OF WASTE <br />CONTAINER TYPO <br />2C. NO. OF <br />20. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s_. <br />CONTAINERS <br />6.4 PGU <br />n <br />Cu FL <br />UN3291Reiutated Medical Waste. n.os., <br />6.2, PGti <br />T849 - 37 Gal Tub(Bio) (4-9 cru ft) <br />Cu Ft. <br />W <br />Regulated Medical Waste, n.os., <br />�^ <br />l- <br />Q <br />6.2, PGI, <br />TB14 - 44 Gal Tub Edo 5. 9 Cu ft <br />v� Cu FL <br />Q <br />a <br />UN32Ii Regulated Medical Waste. rros., <br />,� 1 - 20 Gal Tub {bio) (2.7 cu ft) <br />Cu Ft, <br />W <br />UN3291Regulated Medical Waste, n.os.. <br />6.2. PGii <br />TBlS - 20 Gal Tub Path) (Z.7 Cu tt) <br />Cu Ft. <br />LZ <br />UNM It Regulated Medical Waste. n.os., <br />Cu Ft. <br />UN3291Regulated Medical Waste, n.os., <br />6.2. PGii <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />Qu FL <br />` 93. Generator's Certification: 9 hereby declare that the contents of flus consignment are fully arid accurately TOTALS � �� • Cu Ft. <br />described above by the proper sMpping namel. and are dassilied, packaged. marked and labeiledfplacarded, and <br />are In all respects in proper condition for transport according to applicable international and national governmental regulations' <br />Prince ed Name Signature Data <br />Cr. <br />4. TRANSPORTER t ADDRESS: I Phone 4: �'� <br />N�r�e5- 0 9 9 4 <br />> ' <br />P�S�P <br />Steeicycle, Inc. Q This is a h Shipment Applicable rmit rs. <br />4 <br />4135 W. Swift St Hauler Reg# <br />ECesno,CA 93722 <br />a Q <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as desalbed above. <br />ir <br />~ <br />/2- <br />Printlrype Name _t5,'t�,,�'it�e Signature Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone rt: <br />n <br />� <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Pdntrljrpe Name Signature Date <br />tu <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone 0: <br />Applicable Permit Numbers: <br />w <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of madical waste as doscritteci above. <br />- <br />Printflype Name Signature Date <br />7.01 REPANCY INDICATION <br />Trans d and rs, cu R to , Norm Lake, uT <br />} <br />IIA. Oesignetad Facility: <br />as A Fifty: 8C. Alterlam Facility: ®8D. Atamate FsclAty _ <br />Sbericycte, Inc. <br />Sbutcycie, WK. sb9rlcycte, Inc. Sbirrfgde, Inc. <br />cv <br />�`° <br />4135 W. SWR St <br />so Nam I I GO West 30542 San Antardo Street 2775 E. 26th SI: <br />Fresno,CA 53722 <br />North sea Lake, UT 84(154 H , CA Van=. CA 30Ci53 <br />(559) 276-1121 <br />(801) 936-153.5 (510) 562-2177 (323) 362-300 <br />W 111 <br />11 <br />TS/OST22 <br />3A-448,046 TS31tiS(09T2S TS(OST 26 <br />a <br />lu <br />is TREATMISWAWOW. t certify tha <br />IF rete Toa Wastes <br />I have been authorized by the applicable state agency to accept Untreated medical Wastes and that I have <br />n accordance With the requirement outlined in that authorization. <br />PrintlType Name <br />Signature Date <br />ELA-77, ORIGINAL <br />