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IMEE11CAL WASTETRACICING FORM NUMBER <br />®® Steric c v IN CASE OF EMERGENCY CONTACT. CHEMTREC 1.000.424 -SM MANffXT 001.10 -0e -SM <br />'® ^"'""0 : Route #: 024 - 5 CUSTOMERNM21M <br />1. Generator's Name, Addrew and Telephone Number <br />DEN ISVIM SYPA11A - 569 <br />4545 SMUZY CT <br />STOCKTON, CA 95207- 7232 <br />(249) 477-4273 ? 9 20 <br />CUSTOMER NUMBER 6080856"001 CaussmirsRsatsmnoN0 <br />2A. DESCRIPTION OFWASTE 28. CONTAINER PE 2C. NO. OF 21). VOLUME <br />U IREp d EEedical Wash, n a$CONTAINERS <br />TBOS - 40 "1 Tub (Ri.oi (5.3 Cu it) Cu R <br />s z. l RmdandMWbl Waste, n.o s„ TB49 - 37 Gant Tub (Bio) (4.9 cu it' am <br />® Fa i Medkal Waste, n.0.0, TB14 - 44 G I Tub (Di.n) 15.9 CU tt )JII <br />FI <br />fc &ZP <br />MtI Wash, no B. Tffi1- taro) /T1215 -(Path) jTY15- (Chismo) til Gal rub t2.7a T) Cu <br />1tI Ui13291 Elated M I rt o s, <br />u $.z, <br />poll. <br />%B31- (ei4)1rdP3i- (Paw) /tteG31- tC3�erao) 3z sal xub t 9.14 tFT) <br />o2,rt <br />�PGlfRe ted C„ Wash,nos, e1843-(Eio)IPW43-(tzath)ICw43-{Chemo} tial Tuht5.7CUFT <br />U029i Reonlated Med IM—ftn oa . <br />62. PGI - Biosystems Cardboard Box (4.2 Cu its P. ma <br />3. Generator's CwtlRcalfon:'I hereby dedare that the cments of this co mslnment ere te9y and accuralelyT®TALS ► <br />described above the proper shrprng name, and are dautRed, padtagod, marked and iabe9ed/placarded, <br />4.TRANSPORTER 1 ADDREM, <br />Phone, y <br />-7422 <br />i t ;a <br />.. <br />4135 10. Swift <br />Ave <br />tr <br />IF <br />�T <br />2 <br />Phone A <br />Applicable Permit Nuftera <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of mad cai waste as desordied above. <br />Printrlype Name slonahue Date <br />e. INTERMEDIATE 11ANIJI..ER 30TRANSPORTER 3 ADDRESS: Phone A <br />Applicable Permit Numbew <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: WWI of medmcai waste as described above <br />Printltypo Name Sionalurs Dote <br />T. <br />G <br />ni <br />n: <br />fc <br />been orized by the applicable state agency to accept untreated medical Wastes and that I have <br />ordance With the requirement outlined in that authonzation <br />mo <br />