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ebi <br />a � MEDICAL WASTE TRACKING FORM NUMBER <br />;® Stericycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.600424 STANDARD MANIFEST 001.10 STD <br />• ^ +°'+1r CUSTOMER NO. 21132 A a�!ryRvt�i <br />M11 G'tJ rl ri F1'I.A11 <br />1. Generator's Name, Address and Telephone Number <br />A7"i'N <br />GOLIIEH LIVIt#G EIYPAl&k - 569 <br />4545 SHEiLLEY COURT <br />STOCKTON, CA 95201 <br />1-7nql 477-0721 0� <br />CUSTOMER NUMBER y GENERATows REQwmTan <br />- <br />2A. DESCRIPTION OF WASTE 26. CONTAINER TYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3291, Regulated Medical Waste. n.o.s« <br />CONTAINERS <br />6.2. PGII 1 t <br />Cu Ft_ <br />UN3291. Regulated Medical Waste, n•os.. <br />6.2, PGII 7 ramal Tub(Bio) (4.9 Cu ft) <br />Cu Ft <br />M <br />UN3291.Medical Waste. n.o.s., <br />Q <br />Regulated <br />B14 - 44 Gal Tub (Bio) (5.9 Cu ft <br />Cu FL <br />CC <br />UN3291 Regulated Medal Waste, rt.os. <br />6.2 Pcti Tt32 f - 20 tial rixb {Bi a) (2.7 cu ft) <br />Cu FL <br />W <br />UN3291 Regulated Medical Waste, mo.s., <br />2, <br />6.PGIi TRIS - 20 Gal Tub (Path) (2.7 Gu ft) <br />Cu Ft <br />W <br />Q <br />UN3291Regulated Medical Waste, no.s., <br />62, PGii - ?raAlXtIhr,11Cu <br />Ft <br />UN3291, Regulated Medical Waste, no.s.. <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, rto.s.. <br />6.2, PGII <br />Cu Ft. <br />Cu F1. <br />j <br />3. Generator's Certification: 'I hereby declare that the contents of this consignment are fully and acanatelyT®TALS ® 1 � " Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled0acarded. and <br />are In all respects in proper txrndilion for transport according to applicable international and national ental regutaUorls' <br />,,, <br />-j , jV -Ll 2_ <br />% t l L e774 (0)St <br />Printed/Typed( nature Date <br />Name <br />4. TRANSPORTER 1 ADDRESS: Phone N: <br />53 121 <br />EU <br />ficable Por Numbers: <br />Stericycle, Ina. This is Thro h ShfpmenE�' bora; <br />co <br />4135 West. Swift. Ave. Hauler Reg# 3400 <br />reto <br />Fresno, Ca 93722 <br />It <br />TRANSPORTER CERTIF=ICATION: Remo of medical waste as described above. <br />V& j <br />PdnVType Name G 7 Signature Dale <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone k: <br />N <br />hApplicable <br />Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinitType Name Signature Date <br />6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone C <br />Appkade Permit Numbers,. <br />O W 2 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />2 <br />Printfrype Nanus Signature Date <br />7. DI REPANCY INDICATION <br />Traskred Calftinem, cu 0 to: Mouth Salt Lake, UT <br />} <br />8A Fades -88. Aflamste, FwAty: 0 eC. Alternate Facility: SO. Altamate Facility: <br />3 <br />4 <br />Staricyde Inc -Autoclm Inc- Incineration Stedcyde Inc -Aulodave Stsriryde Inc-Autodave <br />4135 W. SWIFT AVE 90 NORTH 1100 WEST 1345 DOOM DrIWe Ste C 2775 E 26TH STREET <br />t- <br />FPMO.CA 23722 NORTH SALT LAKE CITY, I. rr Sart Leandro. CA 94577 VERNON, CA 90023 <br />(559) 276 - 1121 (m) 936- 1665 (5 10) 562 - 2177 (323) 362 - 3000 <br />DRffANE J 12'i t i 3A -148,1A-36 TW I A S OS T26 TMST -26 <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have <br />P <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />FEB15 2012 <br />PMVTWO Name re Date <br />�.s��;7 <br />