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—MEDICAL WASTE TRACKING FORM NUMBER <br />®O Step IIc�%C!e' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.424-9300 STANDARD MANIFEST 001 -10 -06 -STD <br />• Pmectws .Redu,MPRlrk: Route #: 134 - 11 CUSTOMER NO. 21132 MDFROOHC90 <br />Generator's Name, Address and Telephone Number <br />ATTN : <br />STOCKTON PERSONAL CARE CENTER <br />601 N CALIFORNIA ST <br />STO=ON, CA 95202- 2118 <br />(209) 466-8075 <br />!C. NO. OF 12D. <br />CONTAINERS <br />E <br />1/6/2016 <br />VOLUME <br />CUSTOMER NUMBER 603$'112-002 GENERATOR,sREGISTRATION# <br />P Cu Ft. <br />2A. DESCRIPTION OF WASTE <br />2B• CONTAINERTYPE <br />UN3291 Regulated Medical Waste, n.os., <br />6.2, FGIi <br />TB05 - 40 Gal Tub ('Bio) (5.3 cu ft) <br />6.23291 Regulated Medical Waste, n.o.s., <br />6.2, PGIi <br />TB49 - 37 Cal Tub (Bio) (4.9 au ft) <br />CC <br />UNS291 Regulated Medical Waste, na.s., <br />TB14 - 44 Gal Tub(Bio) (5.9 cu ft) <br />® <br />6.2. PGIi <br />4. TRANSPORTER 1 ADDRESS: <br />Q <br />I= <br />6N3291 Regulated Medical Waste, n.o.s., <br />TB21- (13T0) /TP15- (Path) /Tx].5- (chemo) 20 Gal Tub (2.7CUF <br />W <br />6.23291 Regulated Medical Waste, n.0 s., <br />6.2, PG{i <br />WB31-- (Bio)/WP31- (Path)/WC31- (chemo)31 Gal. Tub(4.14C[ <br />W <br />6 2. PGI1 Requlateo Medical Waste, n.o.s., <br />WB43- {alp) /PW93- {path} /CK43- (Chemo) coal Tub (5.7 CUPT) <br />UN3291. Regulated Medical Waste, n o.s., <br />6.2, PGII <br />RRB - Biosystems Cardboard Box (4.2 cu ft) <br />!C. NO. OF 12D. <br />CONTAINERS <br />E <br />1/6/2016 <br />VOLUME <br />a� <br />Designated Faculty. <br />41 <br />Atfemate Faciffty: <br />Stericycle, Inc. <br />90 N. Foxboro Drive <br />North Salt Lake, UT 84054 <br />(866)783-7422 <br />SC. Alternate Facfiity: <br />Stericycle, Inc. <br />1551 Shelton Drive <br />Hollister, CA 95023 <br />(866)783-7422 <br />80. Alternate Facility: <br />Stericycle, Inc. <br />3140 N 7th Street* <br />Kansas City, KS 66115 <br />(866)783-7422 <br />TSRRT52� 3A -X448 -.1A 36 TS/0-ST 83 TSIOST 26 <br />ttJJAH ((�1 ZQ i6 , . <br />TREATMENT FACILITY. I certify that 1 have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />recelvegft a Indicated wastes I accordance with the requirement outlined In that authorization. <br />Signature <br />Date <br />containers, cu R to _ North Sale Lake, UT <br />x <br />3. Generator's Certification; "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® <br />P Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are in alt respects In proper condition for transport accords g to applicable Intemalional and national gover c s' <br />.. <br />Printed ped Name Signature <br />Date <br />4. TRANSPORTER 1 ADDRESS: <br />Phone # (8 66) 783-7422 <br />U.1 <br />5teriCycle, Inc.® This is a Through Shipment <br />Applicable Permit Numbers: <br />a o <br />4135 W. Swift Ave <br />Hauler Reg¢ 3400 <br />j N <br />Fresno,CA 93722 <br />ja <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />- <br />UC"r <br />Prrnt/iype Nam gnature <br />Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone # <br />CA <br />Applicable Permit Numbers. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinVWe Name Signature <br />Date <br />c� <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #. <br />Applicable Permit Numbers- <br />s <br />ul ol <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />a� <br />Designated Faculty. <br />41 <br />Atfemate Faciffty: <br />Stericycle, Inc. <br />90 N. Foxboro Drive <br />North Salt Lake, UT 84054 <br />(866)783-7422 <br />SC. Alternate Facfiity: <br />Stericycle, Inc. <br />1551 Shelton Drive <br />Hollister, CA 95023 <br />(866)783-7422 <br />80. Alternate Facility: <br />Stericycle, Inc. <br />3140 N 7th Street* <br />Kansas City, KS 66115 <br />(866)783-7422 <br />TSRRT52� 3A -X448 -.1A 36 TS/0-ST 83 TSIOST 26 <br />ttJJAH ((�1 ZQ i6 , . <br />TREATMENT FACILITY. I certify that 1 have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />recelvegft a Indicated wastes I accordance with the requirement outlined In that authorization. <br />Signature <br />Date <br />containers, cu R to _ North Sale Lake, UT <br />x <br />