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<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />IN CASE OF EMERGENCY CONTACT! CHEMTREC 1-000-424.9300 STANDARD NMIFEST 001.10.06 -STD
<br />RnnfiP #(• 134 9 CUSTOMER NO. 21132
<br />1. Generator's Name, Address and Telephone Number
<br />ATTNw 11111111111111111
<br />INAL
<br />STOCKTON MS0141AL CARE CENTER
<br />601 N CAF,IP'CRNIA ST
<br />STOCKTON, CA 95202- 2118
<br />209 466-807&
<br />2/17/2016
<br />CUSTOMER NUMBER 11 -?—no,? GENERATOR's REGISTRATION #
<br />2A. DESCRIPTION OFWASTE
<br />28. CONTAW15FITYPE
<br />2C. NO. OF
<br />20, VOLUME
<br />UN3291 Regulated Medical Wasta,11.os„
<br />6.2, PGII
<br />TBO.S – 40 Gal Tub Bio 5.3 cu ft)
<br />CONTAINERS
<br />Cu Ft
<br />6 2P�I� Regulated Medical Waste,11.o.S,
<br />TB49 – 37 Gal Tub (Oi4) (4.9 Cu ft)
<br />Cu Ft
<br />I=
<br />UN3291 Regulated Medical Waste, 11,04"
<br />6.2, PGII
<br />TB14 — 44 Gal Tub (Bio) (5.9 Cu ft)
<br />L Cu Ft.
<br />R
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6,2, 1`1311
<br />TB21— (BIO) /TPiS— (Patin) /TY:LS— (Chemo) 20 Gal Tub (2.7CUPT
<br />)
<br />Cu Ft
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />NB31– (Sia) /WP31– (loath) /WC31– {Chemo} 31 Gal Tub (4.14CUF
<br />)
<br />Cu Ft.
<br />IZ
<br />UN3291, Regulated Medical Waste, n.o,n„
<br />6.2, PGII
<br />WB43– (Bio) /P1nr43– (Path) /CCIA43– (Chemo) Gal Tub (5.7CUFT)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o,t:,,
<br />6.2, PGII
<br />KRB – Bio stems Cardboard Box (4.2 cu Et)
<br />Cu Ft.
<br />N3291 Regulated Medical Waste, n.o.s.,
<br />6
<br />Cu Ft
<br />Cu Ft
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ®
<br />Y Cu Ft
<br />described above by the proper shipping name, and are classified, packaged, marked and labelied/plao-0, and
<br />are in all respects in proper condition for transport accordingicable International and national govemman gulahons"
<br />Prinledfiyped Name Signature
<br />Date
<br />a
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone d (866) 793-7422
<br />y UJI
<br />SteriCyClee, InC . l..3 This is a Through Shipment
<br />Applicable Permit Numbers:
<br />a o
<br />4135 W. Swift Ave
<br />Hauler Reg## 3400
<br />M
<br />T'resno,CA 93722
<br />a d
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described a
<br />C11
<br />Priompe Name Sig tune
<br />Date
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #•
<br />`V12=�
<br />Applicable Permit Numbers
<br />a ,
<br />y trzrz�Ii �
<br />IIt4TERMEbtA7E HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printltype Name Signature
<br />Date
<br />i,
<br />S. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS. .,
<br />Phone It.
<br />m !
<br />Applicable Permit Numbers:
<br />N a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />x
<br />IE
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />&g
<br />`r
<br />h
<br />Dosignaled Facility: ® 89. Alternate Facility: E] 8C. Alternate Facility- 8D. Altemato Facility: i
<br />ES
<br />Stericycle, Int:. Sterlcycle, Inc. Stericycle, Inc.
<br />Stericycle, Inc.
<br />4135W 90 N. Foxboro Cirive 1651 Shelton Drive
<br />�Nf: 0
<br />3148 N 7th Streettfly
<br />z North Salt Lake, LST $4054 Hollister, CA 95023
<br />Kansas City, KS 66115
<br />z
<br />(866 7> 3-
<br />} (886)783-7422 (888}783-7422
<br />(866)783-7422
<br />w
<br />TS/0ST22 FE8 17 3A448 -JA -36 TS/OST 83
<br />TS/OST-26
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<br />TREATMENT FACiLITYIJ certif that 1 have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />I—
<br />received the above indicatei�'W�'es in accordance with the requirement outlined in that authorization.
<br />Print/i'ype Name Signature
<br />Date
<br />FTransferred
<br />containers, eu R to : North Saft Lake, UT
<br />c�
<br />C�
<br />INAL
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