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ASE OF EMERGENCY CONTACT: CHEMTREC 11-80(4249 <br />r44stericycle- <br />PM0011V hQP1LQ&dQ9ata: Route f: 134 — 10 CUSTOMER NO. 21132 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001 -10.06 -STD <br />MDFROOK6JP <br />1. Generator's Name, Address and Telephone Number <br />21 <br />ATTN: Illi ill llllll II <br />1111111111illi III l Il <br />4 <br />STOCRTOW PERSONAL CARE CENTER <br />601 N CALIFORNIA ST <br />s <br />STOCETO'N, CA 95202— 2118 <br />' <br />(209) 466-9075 <br />1/31/2018 <br />CuBTOMERNUMBER 6038112--002 GENERATOR'S RE1i1STEIATION# <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAiNERTYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN32914,Regulated Medical Waste, n.o.s., <br />6.2, PGI[, ' <br />TBOS — 40 Gal Tub (Bio) (5.3 cu ft) <br />CONTAINERS <br />Cu FL <br />UN3291 <br />2PGI(Regulatad Medical Waste, n,o.s., <br />T849 — 37 Gall Tub {Dia} (4.9 cu tt) <br />Cu Ft <br />® <br />UN3291 Regulated Medical Waste, n.o,s., <br />6.2, PGIE <br />TH1.4 — 44 Gail Tub (Bio) (5.9 au ft) <br />Cu FL <br />Q <br />UN3291 <br />N32 1 Regulated Medical Waste, n.o.s., <br />Tgxl, (SIO) /TP1S— (Path) /Ty.15— (Chemo) 20 coal Tub (2.7CUFT) <br />Cu Ft. <br />W <br />� <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.22,,P01 PGI <br />WB31- (ilio} /WP3l- (path} /WC31- (Chemo) 31 Gal Tub (4 ..14CUF <br />} <br />Cu Ft <br />UN3291 <br />23 A&ti'RogulatedMedical Waste, R,o.s., <br />t zd2- (sza) /PW42- (Pat:h) /CW43- (Chemo) Gal Tub (5.7CUFT) <br />CU Ft <br />UN3291 Regulated Medical Waste, R.O.S., <br />6.2, PGII <br />KRB - Biosystems Cardboard Box (4.2 cu £t) <br />Cu Ft <br />I <br />UN3291 Regulated Medical Waste, n.o.s, <br />6.2, PQI� <br />Cu Ft <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.21 Poli <br />Vol> <br />Cu Ft. <br />3. Generator's Certification: QI hereby declare that the contents of this consignment are fully and accurately TOTALS 1110� <br />i. Cu FL <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 />`tet <br />;PriniedRyped Name`"4 Signature <br />Date t <br />4.TRANSPORTER I ADDRESS: <br />Steele) ® This is a Through Shipment <br />Phone# (966) 783-7422 <br />ale, Inc. <br />Applicable Permit Numbers: <br />Q <br />4135 W. Swift Ave <br />Hauler Regis 3400 <br />a <br />Fresno, CA 93722 <br />TRANSPOR CERTIFJCATION: Receipt of medical waste as described above. <br />Printliype Nam 'SAAIYU ignature """ <br />Date <br />t <br />6. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />1 <br />Applicable Permit Numbers: <br />i <br />INTERMEDIATES HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as desenbed above. <br />Printl•lype Name Signature <br />Date <br />6, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />Applicable Permit Numbers: <br />s <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />j— <br />PdnMpe Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />t <br />�. <br />�t <br />osignated Facility: 8B. Altamtate Facility: ❑ 8C. Alternate Facility: <br />❑ 8D. Alternate Faclllty: <br />Stertcycle, Ina. Stericycle. Ina. Stericycle, Inc. <br />4136 W. SVAftAve 90 N. Foxboro Drive 1$61 Shelton Drive <br />t& <br />Fresno. North Salt Lake. UT $4054 Hollister, CA 95023 <br />E OFIT►Z <br />(866)78 (865)783-7422 (866)783-7422 <br />uJ- <br />TSIOST22 BA448-JA-36 T^a/OST 83 <br />JAN 312018 <br />LU <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above stes in accordance with the requirement outlined In that authonzation. <br />' <br />PrtnMpe Name - Signature <br />Date <br />rand erred containers, CU ft to <br />