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MEDICAL WASTE TRACKING FORM NUMBER
<br />i 0" "p tericyc'e® I SE OF EMERGENCY CONTACT: CHEMFREC 1-000-424-9 STANDARD MANIFEST 0oi•10.OS•STD
<br />• PmGdIn9PWPIaRgdudn91I%R: Route #: 134 — 13 CUSTOMER NO. 21132 MUROOK5LIN
<br />1. Generator's Name, Address and Telephone Number
<br />ATT14. 111111111111111111111111111111111111111111111111
<br />STOCrMN P=SONAL CARE CENTE
<br />601 N CALIlrORNCA ST
<br />STpCKTON, CIS 95202- 2118
<br />(209) 466-8075
<br />1/24/2018
<br />'
<br />CUSTOMER NUMBER 6038'112-002 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OFWASTE
<br />26. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical waste, n.a.s.,
<br />6.2, PGII
<br />TBOS — 40 Gal Tub (Bio) (5.3 Cu ft)
<br />CONTAINERS
<br />Cu Ft,
<br />623 G1 Regulated Medical Waste, n.o,s.,
<br />TB49 — 37 Gal Tub (Bio) (4.9 Cu ft)
<br />Cu Ft.
<br />®
<br />UN3291,
<br />X11, Regulated Medical Waste, n.o.s.,
<br />TB14 — 44 Sal TUb (Biro) (5-9 cu ft)
<br />Cu Ft.
<br />:
<br />QUN3291
<br />Regulated Medical Waste, n.o.s.,
<br />TB21— (Bao) /TP15— (Path) /TYIS— (Chemo) 20 :Gal Tub (2.7CUFT)
<br />62, PGI1
<br />Cu Ft.
<br />W
<br />UN3291 ,Regulated Medleal Wasta, n.p.s.,
<br />WB31- (Bio) /WP31- (Path) /WC31- (Chemo) 31 Gal Tub (4.14CUF
<br />)
<br />W
<br />6.2, PGII,
<br />Cu Ft.
<br />UN3291
<br />2, PGI Regulated Medical Waste, n.o,s., II
<br />kmd3- (Bio) /PW63- (Path) /CW43- (Chemo) Coal Tub (5.7euET)
<br />Cu FL
<br />UN3291, Regulated Medical Waste, n.0.s.,
<br />6.2, PGIICu
<br />KRB - Biosystems Cardboard Box (4.2 cu ft)
<br />FL
<br />UN3291 Regulated Medical Waste, n.%%,
<br />6.2, PGII
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, mo s.,
<br />6.2, PGII
<br />Cu Ft
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately IT LS 110-
<br />Ft.
<br />1Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged; marked and labelied/piacarded, and
<br />are In all respects in proper condition for transport according to applicable international and national governmental regulations."
<br />)X1 Pdnted/'I'yped Name �''c Signature
<br />4. TRANSPORTER 1 ADDRESS:
<br />Stericycle, Inc. This is a Through shipment
<br />Data
<br />Phone#: (866) 783-7422
<br />Applicable Permit Numbers:
<br />4135 W. Swift Ave
<br />Hauler Reg# 3400
<br />m
<br />Fresno,CA 93722
<br />IL 2
<br />TRANSPORT CERTIFICATION: Receiptofmedical waste as described above.
<br />i
<br />I i-a,�1� Y--a�
<br />Prini/TypB Nemo _ 1 1. gnature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />,N
<br />'1h
<br />Applicable Permit Numbers
<br />INTERMEDIATE HANDLEFI /TRANSPORTER CE=RTIFICATION: Receipt of medical waste as described above.
<br />i
<br />Print/Type Name _ Signature
<br />Date
<br />`w
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />eApplicable
<br />Permit Numbers,
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />'
<br />7. DISCREPANCY INDICATION
<br />A. Doalgnatad Facluty: 813. Altemate Facility: El 8C. Attemate Facility:
<br />8D. Attomato Facility:
<br />HH
<br />Sterlcycle. Inc_ Sterlcycle.Inc. Stericycle, Inc.
<br />ca
<br />4156 W. SWRAVO 90 N, Foxboro Drive 1661 Shelton Drive
<br />u°t.
<br />l+resnc,CA83722 North Salt Lake, UT 84064 Hollister, CA 85023
<br />It
<br />(866)783.7422 F TIZ (866)7M7422 (868)783-7422
<br />TS/0ST22 Wil• E Q 3A -44S -JA -36 TWOST 83
<br />P�44
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<br />TREATMENT FACILiT��rfut IIdave been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br />t—
<br />received the above tndtcated wastes in accordance with the requirement outfined in that authorization.
<br />'A(",
<br />Pdnt(Type Name Signature
<br />Date
<br />t-
<br />cans fred conte nem, CU ft to
<br />ty7
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