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— — — ---- — --- — — — MEDICAL WASTE TRACKING FORM NUMBER
<br />.' Siericyclile fikSE OF EMSRGENCY CONTACT. CHEMTREC 1-800-4244STANDARD MANIFEST 001.10.06•STD
<br />° ProtectlnPPeople,ReduddoN,k Route #: 134 - 10 CUSTOMER NO. 21132 jtf(j]FROOK3p4
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN s III 1111111111111111111111111111111111111111111111111111111
<br />STOCKTON PERSONAL CARE CENTER
<br />601. N CALIFORNIA ST
<br />STOCKTON, CA 95202-- 21.1.5
<br />(209) 466-8075
<br />1/10/201.13
<br />CUSTOMER NUMBER (5038112-002 GENERATOwsREGIsTRAn0N#
<br />2A. DESCRIPTION OF WASTE
<br />213. CONTAINERTYPE
<br />20. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2. PGIII
<br />TB05 — 40 Gal Tub (Bio) (5.3 cu ft)
<br />CONTAINERS
<br />Cu Ft.
<br />UN3291
<br />23131311 Regulated Medical Waste, n,o.s.,
<br />TB49 -- 37 Gal Tub (Bite) (4-9 Cu it)
<br />Cu Ft
<br />CC
<br />6 232P811'Ropulatsd Medical Waste, nos.,e
<br />TB14 — 44 Gal. Tub (Bit,) (5.9 cu 'fit)
<br />tj
<br />ti Cu Ft
<br />p
<br />4UN3291
<br />Regulated Medical Waste, n.o,s.,
<br />TB21— talo) /TP15— (Path) /TY1S— (Chmno) 20 Gal Tub (2.7CUFT
<br />6.2, PGI1
<br />Cu Ft.
<br />ul Z
<br />62312611 R6gulated Medlcai Waste, n.o.s.,
<br />WB31— (Bio)/WP31— (Path) /WC31— (Chemo) 31 -Gal Tub (4.140
<br />)
<br />Cu Ft.
<br />LLI
<br />UN3291 .Regulated Medical Waste, n,o,s.,
<br />6.2, Pali
<br />W843— (Bio) /PW43— (Path) /cwd3- (Chemo) Gal Tub (S.7CUFT)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />6.2, PGI1;
<br />KRB — Biosystems Cardboard Box (4.2 cu ft)
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n,o e„
<br />6.2, PGII'
<br />Cu Ft
<br />UN3291„Regulated Medical Waste, n.o.s.,
<br />6.2, 1`611Cu
<br />Ft.
<br />3. Generator's Certification; °I hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />described above by the proper -shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in proper condition for transport according to applicable international and national governmental regulations”
<br />/�
<br />Y♦!A
<br />r
<br />�`� �r
<br />Prfntediryped Name �`/ 413" �' Signature
<br />Date
<br />4. TRANSPORTER 1 ADDRESS; IPhone#:
<br />This is a Through shipment
<br />(866)783-7422
<br />Storicyc e, Inc.
<br />Applicable Permit Numbers:
<br />r 0
<br />4135 W. Swift Ave
<br />Hauler= Reg# 34010
<br />13.
<br />7rXi,%sno,CA 93722
<br />RE
<br />TRANSPORTM C TIFICAT(ON: RRecelpt of medical waste as described above
<br />.�-- t ej
<br />C
<br />PdntPfMpe Nam %2 ni�A/%,( iature
<br />Date
<br />..
<br />6. INTERMEDIATE HANDLER 21TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />`NIq
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature
<br />Date
<br />O. INTERMEDIATE HANDLER3/TRANSPORTER 3ADDRESS:
<br />Phone#:
<br />cc a
<br />a
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMps Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Deaignatod Facility: 813. Altemate Facility: 8C. Altamate Facnity:
<br />❑ aD. Alternate Facility:
<br />r
<br />Sterlcycle, Inc. stericycle, Inc. Stericycle, Inc.
<br />4136 W. SWftAW 90 N, Foxboro Drive 1651 Shelton Drive
<br />w
<br />Fresno, CA 937 North Salt Lake, UT 84064 Hollister, CA 95023
<br />(865)78 O (866)783-7422 (866)783-7422
<br />w
<br />TS/OST22 3A -44"A-36 TWOST 83
<br />WI 1 have
<br />.�
<br />TREATMENTI cert2018ify that I have been authorized by the applicable state agency to accept untreated
<br />ITY: I
<br />medical wastes and that
<br />received the above id0r}�tp�astes in accordance with the requirement outlined in that authorization.
<br />O✓
<br />Print/Type Name Signature
<br />Date
<br />Transferred containers, cu ft to
<br />ORIGINAL
<br />
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