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d. -op Stericycle• IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.424-9300 <br />• I'mtectingPta0&dedudngWA: Route #: 134 — 11 CUSTOMER NO. 21132 <br />t. Generator's Name, Address and Telephone Number <br />ATT1�: II II III I I I II III I II I III III II II <br />STOCKTON PERSONAL CARL CENTER <br />601 N CALIFORNIA ST <br />STOCitTON, CA 95202- 2118 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001-10.06•STD <br />CUSTOMER NUMBER _002 GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OFWASTS 2B. CONTAINERTYPE 20. NO. OF 2D. VOLUME <br />UN3291 Regulated Medical Waste, n.os., CONTAINERS <br />6.2, PGI) TH05 — 40 Gal Tub Sio 3 au ft Cu Ft <br />UN3291, Regulated Medial Waste, n.o.s , <br />6.2, PGII TB49 — 37 Gal Tub {Bio} (4.9 cu ft) _-- Cu R. <br />cc <br />Q <br />CC <br />UJ <br />12 <br />62UN3291Regulated Medical Waste, <br />UN3291 Regulated Medical Waste, <br />6,2, PGI) <br />UN3291, Regulated Medical Waste, <br />62, PGII <br />UN3291, Regulated Medial Waste. <br />6 2 PGII <br />Tt37.4 — 44 ua.L Yuntn3-oi (a•`-1' Cu TL) <br />Ta21-(BTO)/TP15-(Path)/TYi5-(Chemo)20 Gal Tub(2. <br />WB31-(Bio)/WP31-(Path)/WC31-(Chemo)31 Gal Tub(4. <br />Ft <br />wrt4.s— ttu.o) Vedas— tram) E rrwe.t— vnearo Uas. aun Z. rvur-r vu rc. <br />UN3291, Regulated Medical Waste, n o.s., <br />6.2, PGII KRH — Bio stems Cardboard Box 4.2 cu ft Cu Ft. <br />UN3291 Regulated Medical Waste, n.o s., <br />6.2, PGII Cu Ft <br />3. Generator's Certification: "I hereby dtaclare that the contents of this consignment are fully and accurately I TOTALS 110- <br />described <br />►described above by the proper shipping name, and are classified, packaged, marked and labeliedrplacarded, and <br />are in all respects in proper condition for transport according to applicable International and national governmental regulattons" <br />X'Printedrryped Name 111460A Signature a4u� <br />4. TRANSPORTER 1 ADDRESS: <br />UJI Gy ,his is a Through p <br />� Steri c].6: Inc:.InG, ® 9h t3hi mens <br />4135 W. swift Ave <br />2 rn <br />m Fresno,CA 93722 <br />ate. a TRANSPORTER CERTIFICATION* Receipt of medical waste as described abov <br />i— tet- •,.....5Z N. AA & h IN -%A /� �i / t �,---� •-- <br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />I § r <br />1010 <br />w INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />— Print/Typo Name Signature <br />Phone,l- <br />Applicable Pe®rs ItNuin -7422 <br />Hauler Reg## 3400 <br />Date I , �. T "—t <br />Phone #: <br />Applicable Permit Numbers: <br />Date <br />M w 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone N. <br />S Applicable Permit Numbers' <br />y INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/7ype Name Signature Date <br />T. DISCREPANCY INDICATION <br />Designated Facility: <br />Stericycle, Inc. IgASO� <br />4136 W. <br />Fresno,CA 53722 <br />(TS/OST'2241 . 21110 <br />89. Altemate Facility: <br />StericyCle, Inc. <br />90 N. Foxboro Drive <br />North Salt Lake. LIT 84054 <br />(866)783-7422 <br />3A-448-J.A,-36 <br />8C. Alternate Facinty: <br />Sterlcycle. Inc. <br />1551 Shelton Drive <br />Hollister, CA 95023 <br />(866)7133-7422 <br />TS/OST 83 <br />8D. Alternate Facility: <br />Stericycle, Inc. <br />3140 N 7th Streettrfy <br />Kansas Clty, KS 6&115 <br />(866)783-7422 <br />TS/OST-26 <br />TREATMENT FACILITY: 11 -certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above Indicated wastes in accordance with the requirement outlined In that authorization. <br />Print/Type Name Signature Date <br />cq Transferred containers, ca ft to : North Satt Lake, UT <br />0 <br />.rntutttirwa. <br />Cu Ft. <br />