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• ' -- MEDICAL WASTE TRACKING FORM NUMBER
<br /> :®• Stericycle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800- 300 STANDARD MANIFEST 001.10-06-STD
<br /> 1111t.• Protecting People.ReducingRisk: Takfie -#-,7 703 ) t CUSTOMER NO.21132 4U+;.3i)B6CW
<br /> 1.Generator's Name,Address and Telephone Number
<br /> �r. N.- Stacy ��,inolaMEMOIII .
<br /> milli I III 1111111
<br /> SAN tiF t."t:tr il.�.N D1ri �;j '�.f,'f.��.{.�.+ u
<br /> 95207-• 6,304 (209) 954-58-1,5 7,11221/2011
<br /> CUSTOMER NUMBER 60-1 9'}10_.00 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., CONTAINERS
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<br /> 3.Generator's Certification:"1 hereby declare that the contents of this consignment are fully and accurately TOTALS ® l Cu Ft.
<br /> described above by the proper shipping name,and are classified,packaged;marked and labelied/placarded,and
<br /> are in all respects in proper COAoition for transport according to applicable international and national governmental regulations." ;
<br /> PrintedlTyped Name IR"I f' } "I r Signature i Date
<br /> 4.TRANSPORTER 1 ADDRESS: i ? Phone#: (bill 9)2
<br /> LU ater,icn''Cle. nc.,. El "11 1.s 2. , A CI'i:,+s.1,';;h Shipitte-Ilt: Applicable Permit Numbers:
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<br /> O /1i.31 laitst. :-.:1ift Avo._ .[3auler. Reg# ::3400
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<br /> a a TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> ~ I Printrrype Name Signature Date
<br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone C
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<br /> cc¢ Applicable Permit Numbers:
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<br /> w a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> ro 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> a Applicable Permit Numbers:
<br /> a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br /> F z Print(Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> >. E 8A.Designated Facility: 88.Alternate Facility: ®8C.Alternate Facility: 8D.Alternate Facility:
<br /> J Sterlcyde Inc-,�tlb:idave �`tefl e Inc-Isldnera tion Sterlcrde Ir?c-Autodave Sfiet3cyde Inc-Aut adave
<br /> a 4 i 3 t'�'�i.V.,AAFT AVE 90 NORTH 11 Imo' S' 1345 Doolittle Drive Ste s a '2775 E 26TH ,rREET
<br /> W � F l°ESNO CA W3722 NORTH SALT LAKE'Clri,i.I :Sar,Leandro,CA 9457. €rcRNON,CA 9f:1123
<br /> 1— � t 9 "' i t,t t sf3i1 t 93►z- 15.55 (.51 0)su-'21-;7 pn)362-3011x3
<br /> 3A-448-JA-36 `I"S311MIO.ST215 Set S 1 ��s
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<br /> �sTREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> h received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type Name Signature Date
<br />
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