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0 MEDICAL msw TRACKNG FORM NUMBER <br /> 410 INCAS F EpENC6RgffA <br /> IT.CHFATREC 1-800-424-9M STANDARCIMAMFEST001-1046-M <br /> Stericycle* wo Me CUSTOMER NO.21132 MDRC00ILKQ <br /> .1.Generator's Name,Address and Telephone Number <br /> ATTN:Randy Mead <br /> DELTA REHA13 IIII MINOR 1111111111111 I'll I Rill 11 <br /> 1334 S HAM LN 1211WO15 <br /> LODI,CA 95242-3903 (209)334-3825 <br /> CUSTOMER NUMBER 6135842-001 GENERATOWSREGwitmon# <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINERTYPE 2C.140.OF 20. VOLUME <br /> CONTAINERS <br /> UN32111 RegelatedMedicAMste,FLUX., T�B!�4- Elio)ITP14-(Path)44 Gal Tub(5.9 ou ft) Cu Ft <br /> 61 PGII <br /> 1.102911 Regulatedme"Waste,ILOs� /TP1r3-(Palh)/TY15-(Chemo)20 Gal Tub(2.7) <br /> 6.2,PGII Cu Ft <br /> UN3291 Regulateii Medlml Waste,mos. TP49-(Path)I TY49-(Chemo)37 Gal Tub(4.9) Cu FL <br /> Q62,P611 <br /> UN3M.Renitlated Medkal Waste.10-8�- T835-20 Gal Tub(Bio)(3.8 cu ft) Cu Ff. <br /> M 6.Z PGII <br /> ILI U RB1110mild Medi'al Waste,"0-'-, T1304-48 Gal Tub(Rio)(DA cu ft) Cu Ft. <br /> Z 6TFG1I <br /> 'UN329ii ftollitilil Medltal Waste,n it -(Path)I WC-31-(Chemo)31 M Tub(4.14 cu <br /> ,,P. V4P31 Cu FL <br /> 75W-3291l Regulatedlitedical Waste.tios. WE343-(Elo)/PW43-(Path)/OW43-(Chemo)43 Gal Tub(5.7 cu ft) <br /> 6.2,PGII Cu Ft <br /> UN3291 ReguldedMedlealWasteirto.s.. KRB_-Slosystems;Cardboard Box(4.2 ou ft) Cu Ft <br /> 6Z PGII <br /> Cu Ft <br /> TOTALS 01� <br /> 3.Generatitee Certification:"I hereby declare that the contents of this cons=are hilly and accurately ELL CU Ft <br /> described above by the Proper shippirig name,and are clessilted.padtaged, and labelled/plecarded and <br /> are In all respects in proper condition for tranwrt acoopft to applicable Inlemattoml and national tal laroww "111— <br /> a signature Date <br /> Ix <br /> 4.TRANSPORTER I ADDRESS:' L,,V w Phone#. (tStib) 1t1;$-147ZZ <br /> cc <br /> Uj Stericycle,Inc. This is,a ThroUoh ShIpMent ApplrAbIS Permit Nurribers <br /> 11875 While RoCk Rd 3400 <br /> Rancho Cordova,CA 95742 <br /> W <br /> TRANSPOFT"CEFITIFICATION:Remo of medical waste as <br /> EKPrInMpe Name Signature Date <br /> 5.INTERMEDIATE HANDLER 2 ITRANSPORTER 2 ADDRESS. Phone 0: <br /> Applicable Permit Numbers- <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICAMON:Receipt of medical waste as described abDve <br /> Pr[nVrypo Name Signature Date <br /> 6.IWERMEDIATE HANDLER 3 ITRANSPORTER 3 ADDRESS- Phone# <br /> Applicable Permit Numberw <br /> a 0 <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above <br /> Prtntf[Wie Name SWalure Oat. <br /> D7.DISCREPANCY INDICAnON Transferrert I conUainers cu ft Yuba CI,,C OrF no,CA <br /> Transferred—containers. cu It ake, Ur or Fresno, CA <br /> �88.Afte�mMe Facility: 841 Alternate FaCW- n 8D.Alterriate Facility: <br /> MOA,00919nated Fac0r. <br /> -11, <br /> —Stericycle.Ina Stericycle.Inc. Stericycle,Inc. Stericycle,I no. <br /> 1612 Starr Dr. 90 N.Foxboro Drive 4135 W.SM ft Ave 1651 Shefton Drive <br /> Yuba City,CA 95993 North Saft Lake. LIT e4M Fresno,CA 93722 Hollister,CA 95023 <br /> (918)(3e6-6508 (801)930-1171 (GIG)ow550a (888)793-7422 <br /> TS/0ST80 TREATED 3AA48MA-38 TS/0ST 22 TS/OST 83 <br /> Cr TREATMENT-FACILMY,-I certify-that-I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> received TWOMMOM0411iticcirdance with the requirement outlined in that authorization. <br /> Date <br />