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3. Generator'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 all respects In proper condition for transport according to applicable international and national governmental regulations"
<br />Pnntedfi'ypod Name Signature Dale
<br />cc 4. TRANSPORTER i ADDRESS: fPhone #: (866) 783-7422
<br />us Stericycle, Inc. This is a Through Shipment Applicable Permit Numbers:
<br />a awe 4135 W. Swift Ave
<br />o Hauler Reg#) 3400
<br />OL Fresno,CA 93722
<br />a a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />~ Pr1nVType Nam ria Date
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:Phone #
<br />N
<br />I� Applicable Permit Numbers:
<br />R INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />N
<br />Print type Name _ Signature Date
<br />S. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phonecc
<br />#.
<br />nApplicable Permit Numbers:
<br />Ec o
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />IE PrinUiype Name __ — Signature Date
<br />aDesignated Facillty:
<br />-t Stericycle, Inc.�p E
<br />¢ 4135 W. St±+f kl, -
<br />UU- Fresno,CA
<br />(866)7837422 22 d ®�
<br />TS/OSM 1p�
<br />8e. Alternate Facility.
<br />SWricycle, Inc.
<br />90 N. Foxboro Drive
<br />North Salt Lake, UT 84054
<br />(866)763-7422
<br />3A -A48 -JA 38
<br />80. Alternate Facility:
<br />Stericycle. Inc.
<br />1551 Shelton Drive
<br />Hollister, CA 95023
<br />(866)783-7422
<br />TS/OST 83
<br />LJ Co. Altemate Facility:
<br />Stericycle. Inc.
<br />3140 N 7th Streettrly
<br />Kansas CILYi KS 66115
<br />(866)783»7422
<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 I have
<br />received the above Indicated wastes In accordance with the requirement outlined in that authorization.
<br />print/Type Name -� Signature Date
<br />Transterced c:ontalneim, cu ft to : North Sal Lake, UT
<br />— - _ — MEDICALWASTETRACKHVG'FORMNUMBER
<br />0.41-10 Stericycle"
<br />iN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800.4249300 STANDARD MANIFEST 001-10.06•STO
<br />• MatectinpPeople. RedujoIRbk'
<br />Route #: 134 — 9 CUSTOMER NO. 21132 MDFROOHE5M
<br />1. Generator's Name, Address and Telephone Number
<br />]I
<br />`
<br />STOCKTON PERSONAL CARE CENTER
<br />j
<br />601 N CALIFORNIA ST .
<br />j
<br />STOCKTON, CA
<br />95202- 2118
<br />II
<br />(209) 466-8075 1/20/2016
<br />CUSTOMER NUMBER 603$112--402 GENERATOR'S REGISTRA'nON#
<br />2A. DESCRIPTION OFWASTE
<br />2S• CONTAINER TYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />62. PGII Regulated Medical Waste, n.o.s.,
<br />TB05 — 40 Gal Tub (Bio) (5.3 Cu fir)
<br />CONTAINERS
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.a.s.,
<br />6.2, PGII
<br />TB49 — 37 Gal Tub (Bio) (4.9 CU. tt)
<br />1 •
<br />CU Ft.
<br />p
<br />UN3291, Regulated Medical Waste, n.o s.,
<br />6.2, PGII
<br />TB14 — 44 Gal Tub (Bio) (5.9 cu tt)
<br />Cu Ft.
<br />6 N3291,Regulated Medical Waste, n.o.s.,
<br />329
<br />TB21— (BIO) /TP S— (Path) /TYiS— (Chemo) 20 Gal Tub (2.7CUFT
<br />I
<br />Cu Ft.
<br />W
<br />W6.2,
<br />UN3291 Regulated Medial Waste, n.o.s.,
<br />PGII
<br />14831— (Bio) /WP31— (Path) /WC31— (Chemo) 31 Gal Tub (4.14CUF)
<br />Cu Ft.
<br />(�
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />wB43— (Bio) /t?W43— (Path) /cw43— (Chemo) Gal Tub (S.7CUFT)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s,,
<br />62, PGII
<br />KRB — Biosystems Cardboard Box (4.2 cu >t)
<br />Cu Ft,
<br />3. Generator'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 all respects In proper condition for transport according to applicable international and national governmental regulations"
<br />Pnntedfi'ypod Name Signature Dale
<br />cc 4. TRANSPORTER i ADDRESS: fPhone #: (866) 783-7422
<br />us Stericycle, Inc. This is a Through Shipment Applicable Permit Numbers:
<br />a awe 4135 W. Swift Ave
<br />o Hauler Reg#) 3400
<br />OL Fresno,CA 93722
<br />a a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />~ Pr1nVType Nam ria Date
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:Phone #
<br />N
<br />I� Applicable Permit Numbers:
<br />R INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />N
<br />Print type Name _ Signature Date
<br />S. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phonecc
<br />#.
<br />nApplicable Permit Numbers:
<br />Ec o
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />IE PrinUiype Name __ — Signature Date
<br />aDesignated Facillty:
<br />-t Stericycle, Inc.�p E
<br />¢ 4135 W. St±+f kl, -
<br />UU- Fresno,CA
<br />(866)7837422 22 d ®�
<br />TS/OSM 1p�
<br />8e. Alternate Facility.
<br />SWricycle, Inc.
<br />90 N. Foxboro Drive
<br />North Salt Lake, UT 84054
<br />(866)763-7422
<br />3A -A48 -JA 38
<br />80. Alternate Facility:
<br />Stericycle. Inc.
<br />1551 Shelton Drive
<br />Hollister, CA 95023
<br />(866)783-7422
<br />TS/OST 83
<br />LJ Co. Altemate Facility:
<br />Stericycle. Inc.
<br />3140 N 7th Streettrly
<br />Kansas CILYi KS 66115
<br />(866)783»7422
<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 I have
<br />received the above Indicated wastes In accordance with the requirement outlined in that authorization.
<br />print/Type Name -� Signature Date
<br />Transterced c:ontalneim, cu ft to : North Sal Lake, UT
<br />
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