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MEDICAL WASTETRACKING FORM NUMBER
<br />•.p Stericyc'e " INASE OF EMERGENCY CONTACT. CHEMTREC 1-800-424-101STANDARD MANIFEST 001.10.06 -STD
<br />00* Psisissalog Ptople.Redudso Risk 7 _ Route #: 134 - 10 CUSTOMER N0.21132 MDrR4O K£
<br />0Y
<br />Generator's Name, Address and Telephone Number
<br />ATTN:
<br />STOCKTON PXRSONAL CAM
<br />601 N CALIVORNIA ST
<br />STOCK'TAN, CA 96262- 2118
<br />11.0s
<br />09) 466-8075
<br />12- 002 GENERATORS REGISTRATION#
<br />213. CONTAINER TYPE
<br />LtSU22 — 4U t3a1. W110 ELMO; Sa.3 CU1.1
<br />TB49 - 37 Gal Tut) (Bio) (4.9 au W
<br />TH14 - 44 Gal Tub (Bio) (5-9 Ca !t)
<br />TB21- f,n=o)ITL-15- SPat-_h) /T'1riS- (Chemo)20 803, Tub (2.7CUPT)
<br />7
<br />2C. NO. OF 12D. VOLUME
<br />CONTAINERS
<br />I
<br />Ft.
<br />6.MoI, „ . , ..... .... ..., Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PG16 Cu Ft.
<br />CusTOMER NUMBER 69
<br />2A. DESCRIPTION OF WASTE
<br />feriayate, Ina.
<br />4185 W. SwRtAve
<br />Fresno,CA 83722
<br />T:1a;8&6}t18.3� A NEtiir•eee..
<br />03
<br />TREATMEN Ia- d 71
<br />received the above In ca ed we
<br />1 4 Cu Ft
<br />UN3291 Regulated Medical Waste,
<br />6.2, PGI1
<br />623291' Rogulatod Medical Waste,
<br />Cu Ft.
<br />6 28291} Regulated Medical Waste,
<br />®
<br />Regulated Modica[ Waste,
<br />6.2, PGII
<br />aUN3291,
<br />CC
<br />tti
<br />IZ
<br />le
<br />UN3291 Regulated Medical Waste,
<br />6.2, PGII
<br />UN3291i Regulated Medical Waste,
<br />11.0s
<br />09) 466-8075
<br />12- 002 GENERATORS REGISTRATION#
<br />213. CONTAINER TYPE
<br />LtSU22 — 4U t3a1. W110 ELMO; Sa.3 CU1.1
<br />TB49 - 37 Gal Tut) (Bio) (4.9 au W
<br />TH14 - 44 Gal Tub (Bio) (5-9 Ca !t)
<br />TB21- f,n=o)ITL-15- SPat-_h) /T'1riS- (Chemo)20 803, Tub (2.7CUPT)
<br />7
<br />2C. NO. OF 12D. VOLUME
<br />CONTAINERS
<br />I
<br />Ft.
<br />6.MoI, „ . , ..... .... ..., Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PG16 Cu Ft.
<br />7. DISCREPANCY INDICATION
<br />��
<br />UN3%V1 liegulatee McOlcal wasio, n.o's ,
<br />6.2, PGII
<br />I
<br />feriayate, Ina.
<br />4185 W. SwRtAve
<br />Fresno,CA 83722
<br />T:1a;8&6}t18.3� A NEtiir•eee..
<br />03
<br />TREATMEN Ia- d 71
<br />received the above In ca ed we
<br />1 4 Cu Ft
<br />Printfrype Name 44 1—"
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately
<br />Cu Ft.
<br />Steday Inc.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />98 N. Foxboro DrNe
<br />are In all respects In proper Condition for transporrt according to applicable Internatlonal and national governmentalegulations."
<br />1551 Shelton Dove
<br />wig 4 C`�
<br />IF Z^'t 3�' j
<br />j �Printed!'ly ed Name Signature -�
<br />Rate
<br />X
<br />4. TRANSPORTER i ADDRESS:
<br />Phone #:
<br />'(866)783-7422
<br />(866)783.7422
<br />Stericycl-Ee,, Inc, This is a Through Shipment
<br />Appgcabls Permit Numbers -
<br />C)
<br />41351 A. Swift Ave
<br />Hauler Reg# 3400
<br />Freelno,CA 93722
<br />tes In accordance with the requirement
<br />outlined in that authorization.
<br />TRANSPORT CE IFICATlON: Receipt of medical waste as described above.
<br />�.
<br />Pringrype Name + gnature
<br />Date
<br />S. INTERMEDIAT HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />5
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pr1nUType Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers,
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Prinnpo Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />��
<br />. oo gnaterr f=ociaty:
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<br />ua
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<br />feriayate, Ina.
<br />4185 W. SwRtAve
<br />Fresno,CA 83722
<br />T:1a;8&6}t18.3� A NEtiir•eee..
<br />03
<br />TREATMEN Ia- d 71
<br />received the above In ca ed we
<br />i
<br />Printfrype Name 44 1—"
<br />Trans=ferred containers, cu A to
<br />ORIGINAL
<br />a
<br />® 80. Alternate Facility:
<br />lJ 8C. Alternate Facility:
<br />Lj BD. Alternate Facility:
<br />Stedwale, Ino.
<br />Steday Inc.
<br />98 N. Foxboro DrNe
<br />1551 Shelton Dove
<br />North Salt Lake, UT 84854
<br />Hollister, CA SS823
<br />(869)7837422
<br />(866)783.7422
<br />31 -446 -JA -3&
<br />TSMT 83
<br />that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />tes In accordance with the requirement
<br />outlined in that authorization.
<br />Trans=ferred containers, cu A to
<br />ORIGINAL
<br />a
<br />
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