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s <br />•®®• Stericydw <br />• Pmeedav Pe•ot. Redudag RNk: <br />_ MEDICAL WASTE TRACKING FORM NUMBER <br />IN E OF EMERGENCY CONTACT: CHEMTREC 1-800.424-93 STANDARD MANIFEST 001-10.06-STO <br />Route #: 134 - 10 CUSTOMER No. 21132 MDFROOKIV7 <br />1. Generator's Name, Address and Telephone Number <br />AWN; <br />STOCKTON PERSONAL CARE CENTER <br />601 N CALUOR aA ST <br />STOCKTON, CA 95202- 2118 <br />(209) 466-8075 <br />CUSTOMER NUMBER 6038112-002 GF_NERAmn,sREGISTRATION# <br />2A, DESCRIPTION OF WASTE 128. CONTAINERTYPE <br />UN3 910 Regulated Medical Waste, mos., THOS - 40 Gal Tub (Rio) {5.3 Cu ft? <br />62329 j) Regulated MedlotWaste, rwo.s., TH49 - 37 Gel Tub (Biro) (4.9 ou ft) <br />W UN3291 Regulated Medical Waste, n.o.s., TB14 - 44 Gal Tttt) (Bio) (5-9 Cu It) <br />® 6.2, PGH <br />UN3291 Regulated Medical Waste, n.o.s„ T821- BIO TPJ5- Pa TY15- (Chemo)20 (Chemo)20Qat. Tub 1 _ CUNT. <br />6.2, PGII <br />W UN3291 Regulated Medlwl Waste, n.o.s„ WB31- (Bio) /WP31- (path) /WC31- (Chemo) 31 Gal Tub (4.l4CUk" <br />Z 6.2, PGI1' <br />UN3291 <br />3291 RegulatedMedlcalWaste, n.o.s., t 1343--(Elia)/pw62-(Path)/CW43-tehmo) Gal Tub(5.7CUFT) <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PG1E KRB— _ Biosystems Cardboard Box (4.2 au ft) <br />UN3291Regulated Medical Waste, n o.&,6.2, PGIi <br />UN3291, Regulated Medlin Waste, n.o.s., <br />6,2, PGII <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately Y®TALS <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are In all respects in proper tmnditlyngor transport according lWplicable international and national governmental regulations" <br />4. TRANSPORTER 1 ADDRESS: `-" ` <br />rxa Stesicycle, Inc. This is a rot 5'tupment <br />9135 W. Swift Ave <br />< 0 Fresno, CA 93722 <br />a Z TRANSPORTIFICATION: Receipt of medical waste as described above. <br />12/27/2017 <br />20. NO. OF 12D. VOLUME <br />CONTAINERS <br />Cu Ft <br />A #. (t3�.6'- 783-7422 <br />Applicable Permit Numbers - <br />Hauler Reg# 3400 <br />Date 2 -Z -q t <br />5. INTERMEDIATE HAW LER 2 /TRANSPORTER 2 ADDRESS. 1'�---"'� Phone #: <br />N <br />I�� Applicable Permit Numbers: <br />N1 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />- Print/Type Name Signature Date <br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone # <br />Ia § Applicable Permit Numbers. <br />w INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medicol waste as described above. <br />- PrinV7ype Name Signature Date <br />7. DISCREPANCY INDICATION <br />�!2 <br />�w <br />2 <br />I H <br />t-� <br />t` } <br />0 <br />0 <br />8A. Designated Facility: Ela. Alternate Facility: [] 8C. Alternate Facility: [] 8D. Alternate Facility: <br />aterlcycle. IfIc. SUrIcycie, Inc. Stericycle, Inc. <br />4136 W. SMAve 90 N. Foxboro O iva 1551 Shefton Drive <br />Fresno,CA 83722 North Salt Lake, UT 84054 Hollider, CA 95023 <br />(866)783-7422(886)783-7422 (866)783-7422 <br />TS/OOSOAON1~O SA -448 -dA -36 TS/OST 83 <br />TREATMEN'B�AIPITrY: i lrrtify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above indicated wastes in accordance with the requirement outlined In that authorization. <br />PrinVlype Name5lgnatu(e _ Date <br />ORIGINAL <br />