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O s0 Ste r'>icycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800424-9300 <br />• ® PeoledhilPeople. RedudngRisk: Route #:: 134 - 11 CUSTOMER NO. 21132 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001 -10 -06 -STD <br />MDFROOHD7Q <br />1. Generator's Name, Address arid-Felephane Number <br />ATINt <br />STOCKTON PERS074AL CARE, CEN`T`ER <br />661 11 CALUORNIA ST <br />- <br />STOCATON, CA 95202- 2118 <br />(209) 466-8075 <br />1/13/2016 <br />CuSTOMERNUM13ER 6038112--002 GENERATOR'S REGISTRATION# <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINERTYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGO <br />T1305 - 40 Gal Tub (Bio) (5.3 cu ft) <br />CONTAINERS <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s„ <br />TH49 - 37 Gal Tub (Bio) (4.9 cu ft) <br />� <br />4-/l Cu <br />6.2, 13611 <br />Ft <br />6 2 PGII Regulated Medical Waste, n.o.s„ <br />TB3.4 - 44 Gal Tub (BiO) (5-9 Cu Lt) <br />® <br />Cu Ft <br />Q <br />UN3291. Regulated Medical Waste, n.o.s., <br />TB - BZD TP - Ba TYZ - (C emo d eal Tu i2- CUFT <br />l <br />- <br />6.2, PGII <br />Cu Ft <br />U1 <br />UN3291, Regulated Medical Waste, n.o,s„ <br />WB31- (Bio) /WrP31- (Path) ARTC31-- (Chemo) 31 Gal Tub (4.14CUF <br />) <br />6.2, PGII <br />Cu FL <br />IZ <br />a <br />UN3291 Regulated <br />Regulated Medical Waste, n.o.s,, <br />WB43- (Bio) /I?W43- (Path)/CW43- (Chemo) tial Tub (5.7CUFT) <br />Cu Ft. <br />UN3291Regulated Medical Waste, n.o.s , <br />6.2, PGII <br />KRB - Biosystems Cardboard Box (4.2 cu. ft) <br />— <br />Cu FI <br />UN3291 Regulated Medical Waste, n.o.s,, <br />6.2, PGI? <br />Cu R. <br />Cu Ft <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® <br />/ <br />14--7 <br />3. T T . 7 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 to applicable international and national governmental regu tat'01011 <br />Ii n-� <br />C0% <br />I Printed/Typed Name Signature <br />Date <br />4. TRANSPORTER IADDRESS: <br />Sterxcycle, Inc. ® This is a Thro ship ent <br />Phone#: ?$3 742 <br />LU <br />Applicable Permit Numbers - <br />Hauler Reg# 3400 <br />4 a <br />FEesno,CA 93722 <br />in <br />a z <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />` <br />PrinVrype Name Yi Srgnature <br />Data r i3 ittp <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />Applicable Permit Numbers - <br />umbers•a2 <br />DO 2 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Printnype Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />_a w <br />Applicable Permit Numbers: <br />N a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />x <br />- <br />PrinMpa Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />8A. Designated Facility ®8B. Alternate Facility: E] 8C. Alternate Facility: <br />8D. Attemate Facility: <br />SterIcycle, Inc. Staricycle, Inc. Stericycle, Inc. <br />Stericycle, Inc. <br />?T <br />1, Foxboro Drive 1551 Shelton Drive <br />3140 N 7th Stt'eettriy <br />It <br />resno,CAEAM20CLAVE Not b Salt Lake, UT $4054 Hollister, CA 85023 <br />Kansas CKY. KS 56115 <br />f <br />866)78�jpAIN ANNE ORT] Z (8 )783-7422 (866)783-7422 <br />(866)783-7422 <br />W <br />TS/OST22 3A 148 -JA -36 TSIOST 83 <br />TS/OST 26 <br />at` <br />JAN 13 2016 <br />X I <br />TRE A MEI 7., ACILITY. I certify that I have b n authorized by the applicable state agency to accept untreated medical wastes and that i have <br />I.- <br />receiv d thWabove indicated wastes in acoorda nee with the requirement outlined in that authorization. <br />PrInMr a Name Signature <br />Date <br />containers, Cu It to : North Saft Lake, Ul <br />