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5terlcycle• <br />• notecting people Rededng Rhk: <br />*__1M_ <br />EDICAL WASTE TRACKING FORM NUMBER <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-600-424-9300 STANDARD MANIFEST 001.10 -o6 -STD <br />dE• 11A — 11 CUSTOMER NO. 21132 MnTrPnflHG21lI <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />STOCKTON PERSONAL CARL CENTER <br />603. N CALIFORNIA ST <br />STOCKTON, CA 95202- 2118 <br />CUSTOMER NUMBER <br />2A. DESCRIPTION OF WASTE 2H• <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />UN3291Regulated Medical Waste, n o s., <br />6.2. PGII <br />® 6 2329 f Regulated Medical Waste, a.o s., <br />UN3291; Regulated Medical Waste, n o S, <br />6.2, PGII <br />11.11 UN329i, <br />6.2, PGII Regulated Medial Waste, n.os, <br />IZ <br />UN3291, Regulated Medical Waste, n.o s, <br />6.2, PGII <br />mamcal waste, 0.0 s, <br />Medial Waste, n.o s <br />09) 466-8075 <br />GENERATOR,s REGISTRATioN # <br />TBOS — 40 Gal Tub (Bio) (5.3 cu 1:t) <br />TB49 - 37 Gal Tub (Bio) (4.9 Cu ft) <br />TB14 - 44 Gal Tub(Bio) (5.9 Cu ft) <br />TB21-(BIO)/TP15—(Path)/TY15-(Chemo)20 Gal Tub(2.7cuE <br />WB31-(Bia)/WP31—(Path)/WC31—(Chemo)31 Gal Tub(4.14CE <br />W]343—(Bio)/PW43—(Path)/CW43—(Chemo) Gal Tub(5.7CuFT) <br />KRB — Biosystems Cardboard Box (4.2 cu ft) <br />2/10/2616 <br />2C. NO. OF 12D. VOLUME <br />CONTAINERS <br />W <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ®� <br />I 1 i Cu Ft <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 applicable international and national government�relalons," <br />^to <br />Iivb� ' - vip <br />2 A113! 1 <br />Printed/Typed Name Signature <br />Date <br />4. TRANSPORTER 1 ADDRESS: <br />Phone #. <br />(666) 783-7422 <br />aStericyGle, <br />Inc. ® This is a Through shipment <br />Applicable Permit Numbers: <br /><0 <br />4135 No Swift Ave <br />Hauler Reg# 3400 <br />CL <br />rresno,CA 93722 <br />a a <br />TRANSPORTER CERTIFICATION: Recent of medical waste as de bed above. <br />` f <br />Print/Type Nam \/� Signat <br />Date <br />S. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRE S- <br />Phone # <br />Sq <br />Applicable Permit Numbers: <br />cC <br />IWERMEDIATE HANDLER /TRANSRORTER.CERTIF/CATION: Receipt of medical waste as described above. <br />PdnUType Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 31TRANSPORTER 3 ADDRESS: <br />Phone #: <br />ii <br />Applicable Permit Numbers;: <br />Z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />071 <br />Print/type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />?- <br />I+ <br />esignated Facility: 8B. Altemate Facility: SC. Altemate Facility: <br />❑ 8D. Alternate Facility: <br />Stericycle, Inc. DALEMNE }M17 5tericycle, Inc. StarIcycle, Inc. <br />Stericycie, Inc. <br />U<. <br />4136 W, Swift Ave 90 N. Foxboro Drive 1851 Shelton Drive <br />3140 N 7th StmetM <br />f <br />Fresno.CA 93722 North Salt Lake. UT 84M Hollister, CA 96023 <br />(886)783.7422 FEB 1 11016 (866)783-7422 (866)783-7422 <br />Kansas MKS 66116 <br />(866)783-7422 <br />Uj <br />TS/0ST22 3A -448-.1A-36 MOST 83 <br />TWOST-26 <br />TREATMENT FACILITY: I certify that lave been authorized by the applicable state agency to accept untreated medical wastes and that i have <br />a- received the above indicated wastes In accordance with the requirement outlined in that authorization. <br />PrJnf/Iype Name Signature <br />date <br />Transferred containers, 11x11 ft to : North Safi: lake, UT <br />ca <br />W <br />