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®®®®O Stericyele' <br />-MEDICAL WASTE TRACKING FORM NUMBER <br />IN CASE OF EMEROENCY CONTACT: CHEMTREC 1.8884249300 STANDARD MANIFEST ODI-19-O&ST0 <br />p ti+a 6s nDA — A CUSTOMER No. 21132 t.,....w�..-..� <br />. Generator's Name, Address and Telephone Number <br />ATTN <br />N ZaWNG HYRANA - 569 <br />4545 =11MY CT <br />STOCKTON, CA 95207- 7:32 <br />�I�IBIIII�tlIIII111dNIIeI11Y11 <br />Custom NUMBER Q es ReawwwN 0 <br />2A.DESCRIPTION OFWASTE i 213. CONTAINERTYPE <br />UN32�9i1� Regldeted Mldtcal Waste, n.o �, t <br />1 Pagulated , mo.s., — <br />0Z, Pg11 T849 — 37 GaL Trabjaig .9 tt <br />pCUN3291 Ragrdated Medical waste, no.s.. <br />a &Z Poll 78%4 r 44 3 Hie S. u <br />4 MW fed Medical wade, a,os., <br />Ic 6.2.poll <br />TA21—(Sib)ITL"15—(Pat31)/TY15—(Chocma)20 Sal Tubg2. <br />W tM 1 Madfal Webs, n.os., <br />IZ SA <br />Pr:l1 W831-- 81t� /ttrP31—;Pdtlt}/ftc31- a 31 Gal Tubld. <br />1(PSI aced Med l WASIG R o s., <br />1113291 tad I no s„ _ <br />r <br />02 'FW <br />mars _ R nom, a.h...� rr n �.. 4.11 <br />& Generator's Certification: I hereby declare heat the contents of this consign mrit are tally and accUmtely I TOTALS ► <br />Abed above by the proper etdppUtg now, and are classified, packaged, marked and fabolledVacarded. and <br />we In a8 respects In proper condition for transport according to applicable International and national governments! regulations.' <br />%d a c / t _ _ Ir r. . . <br />4 -TRANSPORTER 1 ADDRESS: <br />Stecicycle, :Ear— This is a Through 91h praent <br />4135 14. Swift Ave <br />Fcevao,CA 93722 <br />TRANSPORTER CE C TION: R 1PI of ere ereate, <br />Prkttrt w Nems �h Signature <br />-49 <br />8. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: 1 <br />S. <br />lC. NO. OF <br />CONTAINERS <br />VOLUME <br />Ptmne A t$ 7g3 7422 <br />Applicable t1V,,A a' <br />Sauler Rao 3400 <br />Priate 8: <br />App2cable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of med1coi waste as described <br />PdWfto Name Signatum Date <br />e. INTERMEDIATE HANDLER S /TRANSPORTER 3 ADDRESS: Phone {t, <br />Appilcatde Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Rocelpt of modicai waste an dosaibed above. <br />Print/Type Name Signahua Dain <br />ksignotod Facility: <br />Stertcyrde, Inc. <br />4135 W. SM Ave <br />1=rasrto,CA 9 <br />1 SMST22 2 <br />� . , m !If,K, ,1 w1 certify <br />Transbrred Oo"ners, <br />BE.AltematoFactl y: <br />Skerkyde.Inc. <br />90 N. FOOM Off" <br />Nortit Sat Lal a. UT 8405-- <br />(SM783-7422 <br />38 <br />that�l have been authorized by the apl <br />les accordance with the reaufremen <br />en 4 to : North Sal Laine, UT <br />a <br />1C. Alternate Facithir <br />U BM Alternate Factor: <br />Steticycle.1ne. <br />StElicyde. inc. <br />1551 Shelton OrNs <br />3140 N 7th Streettrtyt <br />Hollister, CA 95l # <br />XAnswC1Y.KS 65115 <br />783 -?422 <br />TSIOST' B3 <br />-26 <br />state agency to accept untreated medical wastes and that l have <br />d in that authotizallon. <br />Date <br />