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"MEDICAL WASTE TRACKING FORM NUMBER <br /> STANDAM <br /> 646 Sterilcycle' INCASE OF GECONEM TACT:CHEMTREC 1-800-424-9300 MANIFM 001-1046-SM <br /> ,rW0.�o WW%aft.*&d.*qRW Route3- 13 CUSTOMER NO.21132 MDRC001HO4 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:Randy Mead <br /> DELTA REHAB 11111111111 <br /> 1334$HAM LN 11117/2015 <br /> LODI,CA 95242-3903 (209)334-3825 <br /> CUSTOMZR NuMaER 6135842-001 <br /> 2A.DESCRIPTION OF WASTE 28. cONTAtNERTYPE 2C.NO.OF 20. VOLUME <br /> 6 UN 0 Regullifted Medhal Waste,n.0 r-,'DjjA-Bio) TP14-(Path)44 Gal Tub(5.13 cu ft) CONTAINERS 2! 91 <br /> 2 <br /> pe Cu FL- <br /> ON3291 emo)20 Gal Tub(2.7) <br /> r 21-( o /TP16-(Path)/TY15-(Ch <br /> ,Replated Medical Waste,11.0 - <br /> PSI j Cu Ft <br /> CC UN3291 I Regulated cal waste,n to)/TP49-(Path)/TY49-(Chemo)37 Gal Tub(4.9) <br /> 62,PGICu FL <br /> !O� UNMI Regulated Medical Waste,0.0-3. T13355-20 Gal Tub(Elia)(3.5 cu ft) <br /> M 62.PGII Cu Ft. <br /> W UN32911 Regulated Medical Waste,nos., 71364-48 Gal Tub(Bio)(6.4 ou it) <br /> zW 62,Pr-11 Cu Ft <br /> 0 <br /> - 3291 Regulated Meftl Waft 11.0-S, <br /> 6.2.13611 VM31-(Bio)/VVP31-(Path)/WC31-(Chemo)31 Gal Tub(4.14 cu R) Cu FL <br /> UNWId Regulated Medcat Waft no.s.. 3-(Bio)!PW43-(Path)/CW43-(Chemo)43 Gal Tub(5.7 cu ft) <br /> 62t PG Cu Ft <br /> ftRegulated M8d1W Waft'Los- KRB.,-Biosystems Cardboard Box(4.2 ou ft) Cu Ft. <br /> 3.Generator's certlacation:I herebyI declare that ft contents of this consigrunerit are f*and aoouW,4*,, T0TAL,S 110- Cu Ft <br /> described above by the proper shipping nam,arxi am classified,packaged,marked and tabellediptacarded,a ---Cu Ft. <br /> are In all respects In proper condition for transport aixordling:rticatuto International and national gover I <br /> L&APdnjWTypad NamS%- Signature, Dt.\ <br /> 4. <br /> icTRANPORr I ADDRESS: Phone4,eyCle,gC #(tsioa) I ts.-t-1 4ZA <br /> This is a Through Shipment Applicable Permit Numb <br /> 11875 White Rock Rd N490 <br /> 20.0 <br /> Rancho Cordova,CA 95742 <br /> aW <br /> TRANSPOPM CERTIFICA11ON:Receipt of medical waste as tf�� <br /> PrInIt"o Nam � N <br /> \&5 Signature Date Vk <br /> Q;. Q��—CA <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS Phone <br /> Applicable Permit Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described attune. <br /> Pdnvlype Nam Signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS • Phone 11. <br /> Applicable permit Numbers <br /> INTERMEDIATE HANDLER/1'4ANSP0Ri E CERTIFICATION:Receipt of ffiedicall waste as described ab". <br /> PrIntrType Name *IFP* �I :M. ==% D <br /> siginatura <br /> 7.DISCREPANCY INDICATION,M lransrrei oonxavner5r-7,%L J culfto-,: at,�Ry, Aort-resno.1-7 <br /> ❑ Transferred containers,—cu It to: North Saffl-ake,UT or Fresno,CA <br /> MR.Designated Facility. Be.Alternate Facility- 11MAttemate Facility. 80.Alternate Facility: <br /> Cycle,Inc. Ster'cycle,Inc. ricycle,Inc. Stericycle.Inc. <br /> Of 1612 Starr Dr. 90 N.Foxboro Drive 136 W.Swift Ave 11661 Shelton Drive <br /> 0 ac. <br /> n, <br /> 6 <br /> r <br /> iZ Yuba City,CA 95993. North Salt Lake, UT 64054 r1esno, CA 08722 -faffister, CA 95023 <br /> (901)026-1171 <br /> (91 & <br /> glis)ae6608 '12166)793-7422 <br /> LWU I <br /> TS/OST 130 t 3A-448/JA-30 OST 22 rS/OST 83 <br /> pit <br /> F <br /> Uj TREMAENT-E I kfify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> race <br /> in accordance with the requirement outlined in that authorization. <br /> fiv <br /> 7- somit" Date <br /> C\1 <br /> —ORIGRIAL <br />