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To: Page 33 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> ——y — - EDICAL WASTE TRACKING FORM NUMBER <br /> so, <br /> S►tencycle° STANDARD MANIFEST 001.10.05-RM <br /> O. CASE OF EMERGENCY CONTACT:CHEMTREC 1-800 424 930 <br /> vm�xWg wroge CUSTOMER NO.21132 MDEIROnunov <br /> 1.Generator's Name,Address and Telephone Plumber <br /> ATTN:IlavG xoaral.cz'yk <br /> illi 1 ll I ll li I l it l I ill it <br /> QEIEs"c DIAGNOST ECS <br /> 2291 g Mj= LN BLDG F <br /> STOCKTON, CA 95207- 6652 <br /> (209) R51-M31 <br /> Ctl=MrstNutdaElt GENERATOR'SRERI$M,Oil# <br /> 2A.DESCRIPTION OF WASTE . 28. CONTAINER TYPE 2C.NO.OF 2D. VOLUME <br /> CONTAINERS <br /> s 7911"Owed Me41cal Waste,n ., <br /> ,4.sCu Fl. <br /> 0320,houbied Medkal Wasie,rto.s., tar Ft <br /> 32MQ 6 2,PSII Regulated Met 1 Waste,n o.e., – 41 Gal T U ., 01 Ft. <br /> UN3291 Regulated 1 Waste,nos., <br /> 6,2,AN Tali–(8xo)/TP15–(Path)/TY15–(Ohwixo)20 Gal tub(2.7C1l8 Cu Ft <br /> ujUN329t Regul�d Medical Waste,n.o.s., <br /> W 6.2,P81� _ Cu Ft <br /> NA <br /> UN3M Regulated Mef�t Waste,aAs., Cu R <br /> UN3291.RegulateryMedl ai Waste,mo.s„ <br /> 6.2,PoR won _ <br /> UN3291 Regulated Medial Waste,nos., — <br /> 6.2,PSIS Ft <br /> r Cu Ft <br /> 3.Generator's Catlf cation:"I hereby declare that lite contents of this consignment are fully and accurately sop, /7,7 Cu Ft <br /> de ad above by the proper shipping nam@,and are classified,packaged,marked and labeAedlplacarded nd <br /> ,WFn r pectw i operrt�it condition for transport according to applicable International and nation over e I regulations" /� <br /> P ntedfiyped Name w•�3 cA/�Ct�_,, —/ ,�, 6 <br /> . ANSPORTER 1 ADORESS: Phone �p gg �1 <br /> a- 6tericycler Inc. This is a Through shipment Appliam®PdrTn���r ��?422 <br /> 4135 W. Swifti Ave Hauler Rieg# 3400 <br /> ZR rcesno CA 93722 <br /> a TRANSPORTE ERTIFICt'�TI 1pt of medical waste as desordmd <br /> Pdntllype Name Signature Dat® <br /> S.lNrERMEDIA7E ITANDLER 9!TRANSPORTER 2 DRESS: Phone d: <br /> +• 7 <br /> -gigApplicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Pdntltype Name signature Date <br /> p, 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 9: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medial waste as descnbed abs. <br /> – Prktt(lyps Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> A.Designated Facility: W.Alternate Facility.- ®1510,Alternate Facdilty: ®aD,Alternate Facility. <br /> is to.Inc. Ste le.Inc. Steric�e Inc. <br /> IItiT�CLAVE 80 .Ft�xbom DrIve 1659 Sheftin arms 8140 N Tai k1y <br /> SUdt a UT $4054 tdallltafar,CA Kensee cab/.KS 66116a 1 h1E©R IZ )T 7422 (866)78"422 t 7422 <br /> 0%*36 TWOST83 TBtOST 26 <br /> iN 180 i6TREATY:I certify that I have b n authorized by the applicable state agency to accept untreated medical Wastes and that I have <br /> h receivecl�Cat�d wast sin accords ce Wtth the requirement outlined In that authorization. <br /> Prinvw �,Gere ne. signature Date <br /> T randemed contalners,-cu R to: Noah Sak Lake,Ur <br /> 00 <br /> Ip <br /> 'F <br /> L <br />