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• MEDICAL WASTE TRACKING FORM NUMBER <br />®® Sterteyele• IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD <br />• Pratuft People RedudnyRitk: Route #: 134 — 10 CUSTOMER NO. 21132 MDEROOHKR.Q <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />ST=MN PERSONAL CARE CENT,LR <br />601 N CALIFORNIA ST <br />STOCKTOH, CA 95202— 2118 <br />(209) 466-8075 <br />UN3291, Regulated Medical Waste, n.o.s., <br />3/9/2016 <br />NO. OF 2D. VOLUME <br />NTA ERS <br />1 <br />CUSTOMERNUM13ER 6038112-002 GENERATOR'sREGISTRATION #Y <br />1 ro _Gu Ft <br />2A. DESCRIPTION OFWASTE <br />2B. CONTAINERTYPE <br />6 2329 , Regulated Medical Waste, n.o.s„ <br />THOS — 40 tial Tub (Bio) (5.3 cu ft) <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />TB49 - 37 Gal Tub (B o) (4.9 Cu It) <br />X <br />UN3291 Regulated Medical Waste, n.os., <br />T11114 — 44 Gil Tub (Bio) (5-9 Cu tt) <br />0 <br />6.2, PGI) <br />4. TRANSPORTER 1 ADDRESS <br />Stericycle, Inc. This is a Through Shipment <br />Q8 <br />232291 GI Regulated Medical Waste, n.o.s., <br />a <br />UJ <br />UN3291, Regulated Medical Waste, n.o.s., <br />U931— (Rio) /Wp3J.— (Bath) WC31— (Chemo) 31 Ga]. T <br />0.2, PGiI <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />tZ <br />6N32291 Regulated Medical Waste, n.os., <br />W1343— (Bio) /pWA2— (Path) /CW43— (Chemo) tial Tub (5. <br />�+ r <br />Date <br />UN3291 Regulated Medical Waste, n.o.s., <br />62, PGII <br />MW — Biosystems Cardboard Bax (4.2 cu tt) <br />UN3291, Regulated Medical Waste, n.o.s., <br />3/9/2016 <br />NO. OF 2D. VOLUME <br />NTA ERS <br />1 <br />i ORIGINAL <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS ® <br />1 ro _Gu Ft <br />described above by the proper shipping name, and are classified, packaged, marked and labelledlplacarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations! <br />�`'` <t✓%4 <br />:7— er-/L <br />Prints ped Name Signature — <br />bate <br />ac <br />4. TRANSPORTER 1 ADDRESS <br />Stericycle, Inc. This is a Through Shipment <br />Phone #: <br />4135 A. Swift Ave <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />Freano,CA 93722 <br />n°C, <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />0Z <br />r <br />PdnUrypo Name <br />�+ r <br />Date <br />e <br />5. INTERMEbIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />Applicable Permit Numbers. <br />01 <br />INTERMEbIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />Print/iype Name Signature <br />Date <br />6. INTERMEbtATE HANDLER 3 /TRANSPORTER 3 ADDRESS- <br />Phone #. <br />a <br />Appiicatste Permit Numbers <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />Printr1ype Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />A. Dealgnated Facility: 86. Altomate Facility: SC. Altemate Facility. <br />❑ 80. Alternate Facility: <br />4 <br />3tericycle, Inc. SterIcycle, Inc. S'tsricycle, inc. <br />4135 W. Swift Ave y�� 0 90 N. Foxboro OWN@ 1551 Shelton Olve <br />Stericyele, inc. <br />3140 N 7th Streettrly <br />u. <br />Fre;anReCA -� No W Lala3, UT 84Q,'�4 H�1lister, GA 95023 <br />l�anslas C�1ie i�5 661 t5 <br />(8&g)983.3422 01� (896)9s�3- �t22 (886)7IM7422 <br />(8607M7422 <br />TSIOST22 ®g 3A-448-JAe"86 TS1= 83 <br />T5/OST 26 <br />h <br />Ca <br />TREATMENT FACILITY: ! certifAltt I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />t— <br />received the above indicated wastes in accordance with the requirement outlined In that authorization. <br />Print/rype Name Signature <br />Date <br />0 t� <br />. , r . �+ � <br />' . Transterre conte ners, cu o . <br />i ORIGINAL <br />