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90®r led c e! CASE OF EM oENCY coiftACT: I C 1-SW4 <br />• • Folmd"► IN Route f g 024 - 3 CUSTOM No. 21132 <br />MDFROOGTU9 <br />1. Generatoes Name, Address and Telephone Number <br />ATT: ii l l i l <br />li I I 111 li i t <br />GO1, M%aNG 133MANA - 569 <br />4545 SHELLEY CT <br />STOCKTON, CA 95207- 7232 <br />(209) 477-0271 <br />0/19/2015 <br />CM0111atNumout9 <br />2A. DESCRIPTION OF WASTE 29• CONTAINER '1 P E <br />2C. NO, OF 2D. VOLUME <br />UNMI.Reqp1sladMailkalMsKnos, <br />CONTAINERS <br />PW TB05 — 40 tial Tub (Bio) (5.31cu ft) <br />Cu R. <br />42. Pt ! WeRe,nos. T849 — 37 Gal Tub (Bio) (4.9=cu ft) <br />� <br />p <br />6.Z PON 11�sts,ace, TB14 — 44 Gal Tub(Bio) (5.9 au ft)11-1 <br />CUR. <br />UNW.ReguisNd wale,nos. TB21-(sxo)eT815-(Falb}7TyC15- chemo)20 tial. Tub(2.7 <br />a Curt <br />) <br />s.Z t <br />Cu Rt <br />us <br />11142111, nos. WB31_(Bio)/VP31—(Path)/rde31^ Chemo)31 Gal Tub(A.14C <br />T ) <br />tt1 <br />Ch <br />�Rro.Ra M Dos. <br />c4pm 19843-(Bio)/Pw43^(Path)/Caf43-(Chemo) Gal Tub(5.7cUrT) <br />Cu Ft <br />UN3W, M ,nos. <br />6a.P4uXRB_ — Biosystems Cardboard °Sox (4.2 cu ft) <br />CUR <br />UIg291, Re , Das., <br />CUR <br />84 Poll <br />CUR. <br />1.11132111, ted MeDos, <br />a2, PGI <br />Cu Ft <br />3. Generator's Certification: 1 hereby dedars that the contents of this wnsGnment are fwly and TOTALS <br />described above by No proper ping name, and are dessloed, packaged, merked and [at�I <br />in aN ds in fru transpe <br />ere r i according to applEcable here gnat and mmne; <br />2 <br />mr7.J <br />4. TRANSPORTER IADD <br />Stericycle, Inc. This a ough Bbipment <br />Phoae9 (866) 783-7422 <br />R <br />4135 A. Swift Ave <br />AppgcaNe Permit Nua berms <br />0 <br />a. <br />Fcesao,CA 93722 <br />Hauler Regi) 34QQ <br />o, TRANSPORTER C TIF CAT[ Receipt of medical waste as des e. <br />! <br />Pdnt/rype Stpnahse <br />Date <br />H <br />5.INTERMEWATE HANDLER 2/TRANSPORTER 2ADDRESS: <br />Pham 9. <br />Appthmbie Permit Numbma: <br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: of rindicat waste ag described abs, <br />Pdntnvpa Name Signature <br />Date <br />n <br />Ii, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone 9: <br />5 <br />t <br />Apprcable Permit Numbers: <br />INTERMEDIATE HANDLER ! TRANSPORTER CERTIFICATION: Receipt of as described above. <br />PdnYrm Name Signature <br />owe <br />7. DISCREPANCY 2VDICAnON <br />Transiemed containers, , _ _� d12 to : North Sak Lake, UT <br />aA.Daalg Rec ft Ott. A tamate Faesrtya ec F . <br />sD. Aitemaie FacgEly: <br />!,Cycle. <br />Inc. Stericycle, Inc. SterIcycle. Inc. <br />4135 W. SWR Ave N. >=oxbor* Dave s 1551 Shel on Drke <br />Stertcyale, Inc. <br />3140 N 71h Str°eettrty <br />LAVE Salt Lake. UT 84054 FtolAster. CA 95029 <br />( )7ti&7 ( 789-7422 (8136)783.7422 <br />Kansas M. KS 66115 <br />TS/O SLE ANNE OR <br />(866(783.7422 <br />g <br />-JArBS +iSJOST83 <br />TWST 26 <br />T ENT FACT • I% X5t i have be n authorized by the applicable stage agency to accept untreated medical wastes and that 1 have <br />F- rereIv the. b6m indicated wastes In accord a with the requIrement outlined III that authorization. <br />� '' '� <br />dnViype St store <br />�1 <br />Date <br />t� <br />