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To Page oom4s zme-0o-1z1n:0s14CDT 18776791797 From:Customer Care <br /> EDICALWASTIE TRACKING FORM NUMBER <br /> 1-800-424-9301M STANDARD MANIFEST 001-10-08-STD <br /> CUSTOMER NO.21132 <br /> 1.Generator's Name,Address and Telephone Number <br /> YOSEMITE ST. DIALYSIS 02442 <br /> MANTECA, CA 95337 <br /> 42.0.2) 924-5-552 32,434,Z2015 <br /> Coavomm NumoER GENERATOR'S REGISTRATION <br /> 2A.DESCRIPTION OFWASTE 20. CONTAINERTYPE 2C.NO.Of 2D. VOLUME <br /> 602�FQll I HWalad Medical Waste.ahs, =5 - AQ rZal Tub (Bio$ (5.3.cu ttl CONTAINERS Cu Ft <br /> UNS291 Regulated Medical MstaIIA s. <br /> L=91 Reoudided Medical Waste,n.o a, <br /> Cu Ft. <br /> W 1.114=1 Regulated Medical Waste,mos., <br /> Uj <br /> 1.1111=1 RelititaledMedicalWate,mos., <br /> UN3291 Regulated Medical Waste,n.o r., <br /> 62,PH <br /> [TaOTALS 10, Cu R <br /> 3.Generator's Certification:'I hereby decigue that the contents of INS oonsignment are fully and accurately Cu FIL <br /> descrIbed above by the proper shipping name,and are classified,packaged,marked and labOled1placa allu <br /> are In all respects In proper condition for transport acoDrdng to applicable International and rfationall governmental`e9ulatlone <br /> Data W <br /> 4.TRANSPORTER I ADDRESS: Phone III: Qllt�IL3;3422 <br /> stericycle, Inc. This 1i a Through shipment Applicable <br /> 4135 W. Swift Ave <br /> Hauler Reg# 3400 <br /> Fresno,CA 93722 <br /> 3. TRANspoFrJER q&MFIGATION:Racelpt of medical waste as described above. <br /> cc <br /> PrIntrlype Name, —SIgnakire Date <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt ol modical waste as doseribod above. <br /> Fdo"Ps Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3 1 TRANSPORTER 3 ADDRESS: Phone#: <br /> Applicable Permit Numbers: <br /> 1 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of insibcall wage as described above <br /> Prinoype"am Signature Dam <br /> T.DISCREPANCY INDICATION <br /> Transferred containers,_cu ft to: North Sak Lake,UT <br /> Inc. SterIcycle.Inc. SWrtcycle,Inc. StarIcycle,Ina. <br /> 41WW CLA% Foxb*M DrNe 1661 Shelton Drive 3140 N 7th Street tffit <br /> F4 <br /> Fmresao No Sol Lake,UT SM fl-lollister,CA 96023 Kansas City,KS 88115 <br /> (8")7 NE ORTIZ (8 6)71831-7422 868)783-7422 <br /> 2 11 8-A-36 TWOST 83 TS/OST-28 <br /> DEC 1428-15 <br /> TR ova <br /> CILITY:I cartity that I have authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> rec We a indicated wastes In,acco nce with the requirement outlined in that authorization. <br /> Prin po Name Signature Date <br />