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O • Ster€ cie° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-000.424.9300 <br />❖ '10t0t0 "�Q ®ems` Tta,ut;e S,.. 100 — 241 CUSTOMER NO. 21132 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001-10.06-M <br />t+in RoonipR9 <br />G►li1101e'tt l <br />1. Generator's Name, Address andTelaphone Number <br />ATTR. 111111 oil 111111 <br />CALIFORM 1401CAL WMaLITY <br />I <br />1617 IN CALIFCREIA 5T <br />STOCRMV, GA 95204- 6117 <br />(209) 948-6435 <br />5/14/2013 <br />I <br />CuSromen Numae n 2 GONEnmws ReewmA'noN 4 <br />2A. DESCRIPTION OF WASTE 28. CONTAiNERTYPE <br />2C NO. OF <br />2D. VOLUME <br />UN3291 Regulated Medical Waste, Ti o s, <br />6.2. PGII 'Y`W5 — 44 Gal Tub (Rio) 45.3 cu 1:t;# <br />CONTAINERS <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o c., <br />62, PGIt TB49 — 37 tats Tub (iro) (4.9 cu ft) <br />Cu Ft <br />p <br />R Gtl Regulated Medical Waste, n.a.s.,ra. Ori Gall Tub(SW (5.9 CIA Ttli <br />® Cu Ft <br />6.2, Ali Regulated Medical Waste, n.os, TB21 - 20 Gat T►xh{i o) (2.7 cu ftt <br />Cu Ft <br />W <br />UNa291 Regulates! Medical Waste, n as., <br />tit, PGII TP15 — 20 Saz Tub 4PAth) 42.7 CU M <br />Cu Ft. <br />UUNNS22991� Regulated Medical Waste, n.o.s., <br />62, TY15 — 20 eat. Tub (Chem*) 42.7 ter ft) <br />Cu Ft. <br />UU022991 Regulated Medical Waste, rms., <br />11,21 - viogyatew Cardboard no= (4.2 cu itf <br />Cu Ft <br />291 Regulated Medical Waste, n.os., <br />62. 29 <br />Cu Ft. <br />pbab7aaceurACax vast <br />Cu R. <br />3. Generator's CerUftcationr h hereby declare that the contents of time consignment are fully and acarrately <br />described above by the proper shipping name, and are classified, packaged, marked and labelleWplacarded, and <br />dre In all respects in proper condition for silo according to applicable inter at and national gover re ulabon <br />XimniedflWied AA <br />Name Signature <br />4. TRANSPORTER i ADDRESS: r VPhone <br />8; r <br />� X21 <br />���ur <br />Sttecicycler lnr:. Tads is rx Through BhivmeQ Applicable Permit Numbers, <br />'Q <br />41.35 X. swift: Sit: <br />Hauler Rio 3400 <br />FcevaorCA 93722 <br />a <br />'TRANSPORTER CERTIFICATIO A Recelpt of medical waste as described above. <br />/AA!' <br />Print/Type Name signature Dateop <br />,. <br />ev <br />6. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone A <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER ITHANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS; Phone d. <br />Applicable Permit Numbers <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />x <br />all <br />is <br />Print/iypa Mame Signature Date <br />7. DISCREPANCY INDICATION <br />ema tx tirtal Its it to . North Sak Eako, IIT <br />, <br />%00 . dirsignated Facility: 8B. Alternate Facility: ® 8C. Alternate Facility. ❑ 80. Alternate Facilliyr, <br />8tericycte, Inc. StwIcyde. Inc. Mad=c- <br />S daycle�, Inc. <br />Q <br />4135 W. SM St 90 Notch 1100 vVe35t 1651WWI, <br />2776 E. 26th St, <br />Fmno.CA am North Sad [.aIle, UT 84W4 HoWsbr, CA StS412<i <br />Vemon. CA 90058 <br />( 275-1121 (SDI) w5-1665 (831) X630-1098 <br />(323) 362-30M <br />-AVE <br />36 T3IU97' f33 <br />TSICrSE=2& <br />TREA %NfrRk JKt f;, khat I have been authorized by the applicable state agency to accept untreated medical <br />wastes and that t have <br />rqc i ed tthMhee above Indicated wastes i accordance With the requirement outlined in that authonzation. <br />2013 <br />in NtrftY Signature <br />Date <br />" 4 � fifi:l•f6G ' <br />G►li1101e'tt l <br />