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p; o S�ericg/cle' <br />bolecft People. Aedudng Rbk. <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.600.424-9300 <br />Route #e 134 — 10 CUSTOMER NO. 21132 <br />MEDICAL. WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001 -10.08 -STD <br />1. Generator's Name, Address and Telephone Number <br />ATTN:III1111111111111111111111111121111111111110 <br />11 <br />STOCiiWN PERSONAL CARE CENTER <br />601 N CALIFORNIA ST <br />STOCKTONt CA 95202- 2118 <br />CUSTOMER NUMBER 6039 A-2-002 GENERATOR'S REGisTRATION # <br />21L DESCRIPTION OFWASTE 21 CONTAINERTYPE <br />2C. NO. OF 2D. VOLUME <br />UN3291 Regulated Medical Waste, n o.s., <br />62, PGti <br />CONTAINERS <br />Cu Ft. <br />6 22 291 1 391Regulated Medical Waste, n.os., <br />Cu Ft. <br />® <br />291 Regulated Medical Waste, n.o.s., <br />� � 1 Cu Ft. <br />6U2 <br />Q <br />a <br />6 2, FGII Regulated Medical Waste, n.o.s., <br />T821- (BIO)/TP15- (Path)/T.YiS— (Chemo) 20 Gal Tub (2.7CUEfi) <br />Cu Ft <br />W <br />UN3291 Regulated Medical Waste, n.o s, <br />6.2, PGI <br />— 1— em 1 Ga1 Tub 4.2 CUF <br />Cu Ft. <br />111 <br />L, <br />Regulated Medical Waste, n.o,s., <br />6UN232911, <br />_ <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGI <br />_ Rio qt--PinisCu <br />Ft. <br />UN3291 Regulated Medical Waste, n.os., <br />6.2, PGIJ <br />Cu Ft <br />UN3291• Regulated Metrical Waste, n.o.s., <br />6.2, PGti <br />Cu Ft <br />$ <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately <br />t It: 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 />;Printeciriyped Name _( ✓ �G n �^,�" f �ei Z7.—Signature <br />Date 2 - Z y— t� <br />a <br />4. TRANSPORTER 1 ADDRESS: <br />Phone # <br />((Rtt <br />b%g�T422 <br />y. <br />� <br />Stericycler Inc. is a Through shi. taent <br />P <br />ApplicablepjAgQ77 <br />4135 W. Swift Ave <br />Hainer Reg# 3400 <br />00. <br />in <br />FreanorCA 93722 <br />a <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as des ' ed above. <br />�- <br />L <br />Pnntltype Nam ignature <br />Date <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #; <br />SApplicable <br />Permit Numbers* <br />08 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinUlype Name Signature <br />Date <br />M <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone # <br />SApplicable <br />Permit Numbers: <br />N <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, <br />Prinnpe Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />?-5L.M60asignatod <br />Facility: 89. Alternate Facility: ❑ 8C. Altemate Facility: ® 80. Alternate Facility: <br />USterlcycle, <br />pA!-E! JNO <br />Inc. S ricycle, Inc. Stertcycte, Inc. <br />Stericycle, Inc. I <br />X< <br />4135 W. Wit AVS 80 N. Foxboro Drive 1551 Shelton Drive <br />3140 N 7th 5treettliy I <br />F <br />FreBno,CA 93722 FEB 2 4 2016North Salt Lake, Lir 84084 Hollfeter, CA 96028 <br />Kansas CW, IGS 6611S <br />Z <br />(866)783-747.2' (866)783-7422 (866)783-7422 <br />(866)783-7422 <br />QTS/OST22 <br />Aet 3A -448 -JA -36 TS/OST 83 <br />TWOST 26 <br />I! <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical <br />wastes and that I have <br />I— <br />received the above indicated wastes in accordance with the requirement outlined in that authorization <br />Print/type Name -Signature <br />Date <br />Transferred containers, cu ft to : North yak Lake, UT <br />r, <br />