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e ,g, p■ t • Pm1Mkg"I. Redut(ng Alik: T' MEDICAL WASTE TRACKING FORM NUMBER 1 SE OF EMERGENCY CONTACT: CHEMTREC 1-SOtM24-g STANDARD MANIFEST 001.10.06SM mute #: 134 — 9 CUSTOMER NO. 21132 MDFROOK200 1. Generator's Name, Address and Telephone Number ATTN: STOCKT'ON VERSONAL CARE CEi+TM 601 N CALIFORNIA ST ST)r-=N, CA 95202- 2118 (209) 466-8075 1/3/2018 7. DISCREPANCY INDICATION 8A. Deaignatod Faculty. L_I 8B. Altomato Facility. jJ 8C.Alter'nate Facility: Lj 80. Altemate Facility: Stericycle, Inc. Sterlcycle, Inc. Stericycle, Inc. �-- 4135 W. Swift AV* 90 N. Foxboro Drtve 1651 Shelton Drive Fresno CA 93722 North Salt Lake, UT 84054 Hollister. CA 95023 (868)763-74 (866)783.7422 (8136)788-7422 TS/OST22 SA -448%W36 TS/0ST 83 ✓40 EATMENT FACIE: I cert kat j have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have �efved the i0ove irlidlelled wastes In accordance with the requirement outlined In that authorization. Name Date CUSTOMER NUMBER 6038112-002 GENERATOR'S REGISTRATION# 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO. OF 2D. VOLUME UN3291 Regulated Modica] Waste, n.os.,CONTAINERS 6.2, PGI] T805 — 40 Gal Tub (Bio) X5.3 cu ft} Cu Ft. 6N32991ii Regulated Medical Waste, n.o.s., TB49 » 37 Gal Tub (Bio) (4-9 au Et) ::y± i Cu Ft. It, UN3291 Regulated Medical Waste, n.o.s., 6.2, P6 [I �TB14 — 44 Gal Tub (Bio) (i-9 9 cu 'Pt} Cu Ft. Fp Q UUN32P9111; Regulated Medical Waste, n.o.s., TB21— (82o) /Tpl.5— (Path) /TY15— (Chemo) 20 Gaal Tub (2.7CUFT Cu FL W UN3291 Regulated Medical Waste, n.os., WB31—(Bio) /WP31— (Path) /WC31— (Chemo) 31 Gal Tub (4.14CUF ) Z 6.2, PGII Cu FL UN3291 81 oll Regulated Medical Waste, n.os., WRJ2— (gist) /pw49- (Path) /GWW43— (Chemo) Gal Tub (5.7CUFT) cu Ft. 6 2 pGl� Regulated Medical Waste, n.o.s.,XRB _ Biosystems Cardboard Box (4.2 cu £t) Ou FL- UN3291 Regulated Medical Waste, n.o.s., 6.2, PG [I Cu Ft. UN3291 Regulated Medical Waste, n,o,s., 6.21 PGlI I J 0 Cu Ft 3. Generator's Certification. "I -hereby declare that the contents of this oonslgnmerjt are fully and accurately TOM ALS Cu Ft. described above by the proper shipping name, and are classified, packaged, marked and labelled/plaoarded, and are In ell respects n proper Condition for transport according to applicable IntematioRal and national governmental regulations.' Y I Pdnted/lyped Name Signature 4. TRANSPORTER 1 ADDRESS: Steriayale, Inc, This is a Through shipment Date Phone#: (866) 783-7422 AppfcabiePermit Numbers: 4138 We Swift Ave Hauler Reg# 3400 90 N Fresno,CA 93722 a TRANSPORT CE TIFICATION: Receipt of medical waste as described above. Pr]nVfte Na �/`�1 �� in Signature Date K. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #: 11.4 11 a Applicable Permit Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. PdnVTypo Name Signature Date M 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone # Applicable Permit Numbers - INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Pr[ntfiype Name Signature Date 7. DISCREPANCY INDICATION 8A. Deaignatod Faculty. L_I 8B. Altomato Facility. jJ 8C.Alter'nate Facility: Lj 80. Altemate Facility: Stericycle, Inc. Sterlcycle, Inc. Stericycle, Inc. �-- 4135 W. Swift AV* 90 N. Foxboro Drtve 1651 Shelton Drive Fresno CA 93722 North Salt Lake, UT 84054 Hollister. CA 95023 (868)763-74 (866)783.7422 (8136)788-7422 TS/OST22 SA -448%W36 TS/0ST 83 ✓40 EATMENT FACIE: I cert kat j have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have �efved the i0ove irlidlelled wastes In accordance with the requirement outlined In that authorization. Name Date