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MEDICAL WASTE TRACKING FORM NUMBER
<br />®• �+ e e STANDARD MANIFEST 001.10.06 -STD
<br />ter icycle IN CASE OF EMERGENCY CONTACT: GHEMTREC i -8i]0 424-9300
<br />• PrMecdrpPeopkReduclnpRi,g; Route #: 134 — 11 CUSTOMER NO. 21132 MDFROONJ 7
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN
<br />STOCK`1'ON PERSONAL CARE CENTER
<br />601 N CALIFORNIA ST
<br />sncxToN, CA 95202- 2118
<br />(209) 466-8075 3/2/2015
<br />CUSTOMER NUMBER
<br />Waste,
<br />GENERATOR'S REGISTRATION #
<br />TH05 - 40 tial Tub (Bio) (5.3 cu tt)
<br />TB49 -- 37 Gal. Tub (Bio) (4.9 CU ft)
<br />TB14 - 44 Gal Tub(Bio) (5.9 Cu $t)
<br />T821-(EI0)/TP15-(Path)/TY15-(Chemo)20 Gal Tub(2.7
<br />WB31—(Bio)/WP31--(Path)/WC31—(Chemo)31 Gal Tub(4.1
<br />3. Qenerator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in ail respects in proper condition for transport according to applicable International and national governmental regulations"
<br />n_E a�JR.��JA,�— / n ./-J/ IA1 At I?f17AAL R,nnah,rn
<br />4 c 4. TRANSPORTER 1
<br />tv
<br />206
<br />pME
<br />, q TRANSPORT
<br />(ne
<br />Stericycle, Inc.
<br />4135 W. swift Ave
<br />>rresno,CA 93722
<br />CERTIFICATION: Receipt of i
<br />® This is a Through Shipment
<br />waste as described above.
<br />2C. NO. OF 120.
<br />CONTAINERSI
<br />VOLUME
<br />Ft
<br />I
<br />1 L Cu Ft
<br />Date
<br />Phone #- A8�%783-7422
<br />Applicable rent mbers•
<br />Hauler Reg# 3400
<br />Date
<br />5. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS; Phone #:
<br />Nh N
<br />Applicable Permit Numbers,
<br />. 13
<br />17J
<br />N INTERMEDIATE HANDIER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />— Print/Type Name Signature Date
<br />—6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS' Phone #:
<br />Applicable Permit Numbers
<br />Nit a INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />— PrinVtype Name Signature Date
<br />z
<br />Lu
<br />17. DISCREPANCY INDICATION
<br />SQA. Designated Facility:
<br />2A. DESCRIPTION OF WASTE
<br />E] 8c. Alternate Facility:
<br />UN3291 Regulated Medical Waste, n o.s ,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGiI
<br />112 Sterlcyele, Inc.
<br />6UN3 91 Regulated Medical Waste, n.0 s.,
<br />®
<br />Q
<br />cc
<br />W
<br />U
<br />(j
<br />UN3291 Regulated Medical Waste, n o s.,
<br />6.2, I'M
<br />UN3291, Regulated Medical Waste, mo a.
<br />6.2, PGII
<br />UN3201, Regulated Medical Waste, n.os ,
<br />6.2, PGiI
<br />UN329i, Regulated Medical Waste, n.o.s.,
<br />Fresno,CA 93
<br />A 2
<br />Waste,
<br />GENERATOR'S REGISTRATION #
<br />TH05 - 40 tial Tub (Bio) (5.3 cu tt)
<br />TB49 -- 37 Gal. Tub (Bio) (4.9 CU ft)
<br />TB14 - 44 Gal Tub(Bio) (5.9 Cu $t)
<br />T821-(EI0)/TP15-(Path)/TY15-(Chemo)20 Gal Tub(2.7
<br />WB31—(Bio)/WP31--(Path)/WC31—(Chemo)31 Gal Tub(4.1
<br />3. Qenerator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in ail respects in proper condition for transport according to applicable International and national governmental regulations"
<br />n_E a�JR.��JA,�— / n ./-J/ IA1 At I?f17AAL R,nnah,rn
<br />4 c 4. TRANSPORTER 1
<br />tv
<br />206
<br />pME
<br />, q TRANSPORT
<br />(ne
<br />Stericycle, Inc.
<br />4135 W. swift Ave
<br />>rresno,CA 93722
<br />CERTIFICATION: Receipt of i
<br />® This is a Through Shipment
<br />waste as described above.
<br />2C. NO. OF 120.
<br />CONTAINERSI
<br />VOLUME
<br />Ft
<br />I
<br />1 L Cu Ft
<br />Date
<br />Phone #- A8�%783-7422
<br />Applicable rent mbers•
<br />Hauler Reg# 3400
<br />Date
<br />5. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS; Phone #:
<br />Nh N
<br />Applicable Permit Numbers,
<br />. 13
<br />17J
<br />N INTERMEDIATE HANDIER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />— Print/Type Name Signature Date
<br />—6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS' Phone #:
<br />Applicable Permit Numbers
<br />Nit a INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />— PrinVtype Name Signature Date
<br />z
<br />Lu
<br />17. DISCREPANCY INDICATION
<br />SQA. Designated Facility:
<br />® 88. Alternate Facility:
<br />E] 8c. Alternate Facility:
<br />E] So. Alternate Facility:
<br />Stericycle, Inc. DALE ANNE OR
<br />112 Sterlcyele, Inc.
<br />Sterlcycle, Inc.
<br />Stedcycle, inc.
<br />4138 W. SWIM Av0
<br />90 N. Foxboro Drive
<br />1551 Shelton DrIve
<br />3140 N 7th StrMettfty
<br />Fresno,CA 93
<br />A 2
<br />North Salt Lake, UT 84M
<br />Holffster, CA 85023
<br />Kansas City, KS 6611 S
<br />(866)783-7429 >��6
<br />(866)78&7422
<br />(866)783-7422
<br />(866)783-7422
<br />MOST22
<br />3A -4413 -JA -36
<br />TSIOST 83
<br />TS/OST-26
<br />!TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that t have
<br />(!received the above indicated wastes in accordance with the requirement outland in that authorization
<br />Prinnpe Name Signature Date
<br />Transferred containers, cu ft to : North Sah Lake, UT
<br />ORIGINAL --
<br />--- _ — -
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