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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stericycle' E 011` ME Y CO CT:CHEMTREC 11-80009300 STAW E2! Itr-06-STD
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<br /> pmesting People.Reducing Risk: CUSTOMER NO.21132
<br /> 1.Generator's Name,Address and Telephone Number
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<br /> !'15.1 'PAC"IFIC AA&
<br /> STOCKAX"JQ4, CA 91,0 -7-
<br /> CUSTOMER NUMBER 6f,i 3.1_17 10--0 1)2 GENERATOR'S REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C.NO.OF 2D. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., -H 57 90 G�xJL Tub (TPjx.0 (12 cu ft:) CONTAINERS
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<br /> UN3291,Regulated Medical Waste,n.o.s., `•':=.419 37 fig-,A1 Tub (Nx0) #4.14 C1.1 Tt-.)
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<br /> CC UN3291,Regulated Medical Waste,n.o.s., TU14 44 i4al TIAJ7 .111($, 7-9 f;'A L71
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<br /> Ur UN3291,Regulated Medical Waste,n.o.s., TY15 -20 Gal Tub SCisestteph .(?.7 Cu tt)
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<br /> UN3291,Regulated Medical Waste,n.o.s.,
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<br /> UN3291,Regulated Medical Waste,n.o.s.,
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<br /> P13arnia,z-!u1:1oaJL Wast
<br /> 3.Generator's Certtfication:"I hereby declare that the contents of this consignment are fully and accurately TOTALS 10,
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<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and
<br /> are in all respects in proper condTn for transport according to applicable international and national governmejal regulations."
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<br /> Xprintadl/Typecl Name AZ-711, Signature
<br /> 4.TRANSPORTER 1 A,,DPRE_
<br /> Phone#,
<br /> Will 4135W�-st Swift Ave. AppWe-fZrp)ithu rs;,
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<br /> 0 J., 19.3322:
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<br /> IL Z TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature
<br /> Date I
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: `- Phone#:
<br /> Applicable Permit Numbers:
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<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Print(Type Name Signature Date
<br /> cam 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
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<br /> m Applicable Permit Numbers:
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<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION Transferred Containers, A. cu ft to - North Sialt Lake,UT
<br /> 8A.Designated Facility:
<br /> 8B.Alternate Facility: E]8C.Alternate Facility: E)8D.Alternate Facility
<br /> 'neratti. , -Autodave
<br /> 63 SferlrNcle tric-ALtridave Stericycle Inc,Ind' -,n Stericycle Inc-Autocive S- RI .a
<br /> 413-W.VVIA F T�4Y E 90 N ORTH I IUD VVEST 1345 0oolift DrNe Sto C 2775 E N'TH SIREET
<br /> 8an Leandro,CA 94677
<br /> VERNON,CA 90023
<br /> .4 IN FRESNO,CA 93'2 122 NORTH SALI'LAKE CiTY,1.11
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<br /> -5 59)375- 112 1 11)gas- 1555 (510)582-2177 pnj 362-it
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<br /> W &I TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> P received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type Name Signature Date
<br /> I Fays-&T r.iPixRFPa7,nip
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