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<br />`°® trotatrirePeple Rick:
<br />0 MEDICAL WASTE TRACKING FORM NUMBER
<br />I OASg OF ME %CY CO GT CHEMTREC 1.800424-930 STANDARD MANIFEST {101.10.0&STD
<br />C� CUSTOMER NO. 21132 mDFR00DQW
<br />. Generator's Name, Address and Telephone Number
<br />ATTu:
<br />CALITCU1111A PMDICAL IMLITY
<br />1617 'N CALTFCMA ST
<br />STLJM'L"4It CA 95.2$4- 61.17
<br />11II�II�I�IIIIIBA�tl11111111
<br />(2091) 9148-6435 6/21/2013
<br />Phai maceut icxal Wast
<br />teneratoes, Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS 111,
<br />oribed above by the proper shipping name, and are classified, packaged, marked and labelleatpfacarded, and
<br />In all respects In proper cooed' it�tan for transport according to applicable international and national governmental r/eaulaho "
<br />4. TRANSPORTER 1 ADD
<br />SfcCycle, XaC. This as a Thxeu:gh Jltd:p netst
<br />4135 W. Swift: St
<br />0 Ycenn.o, CA 93722
<br />a
<br />�
<br />TRANSPORTER CERTIFICATION: ReceEpt of medcai waste as deacnbe'�''�_...--^'��
<br />8. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS:
<br />oa
<br />9
<br />Eli INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of madxal west® as described above.
<br />Prtnt/7ype Name Signature
<br />cry,. I S.INTERMEDIATE HANDLER S/TRANSPORTER 3 ADDRESS:
<br />20. NO. or 2D. VOLUME
<br />CONTAINERS
<br />® ZIJ--
<br />Phone #: k0*!f) c fa—.t1Z1
<br />Applicable Permit Numbers:
<br />8au%l: Reg# 3400
<br />Date _
<br />Phone 0:
<br />Applicable Permit Numbers:
<br />Data
<br />Phone 0:
<br />Applicable Permit Numbers:
<br />CUSTOMER NUMBER 6039652-002 GzueRAToraREarsTnATroar#
<br />2A. DESCRIPTION OR WASTE
<br />20, CONTAINERTYPE
<br />cede, Inc. , Inc. ftdcycle Inc.
<br />POI) Regulated Medical Waste, nes.,
<br />M5-- iib tial, Tub (Bio) (5_3 cu ftp
<br />UN8291, Regulated Medical Waste, nos.,
<br />6.2, PGiI
<br />TH9 - 37 Gal Tub (Biot' (4.9 ca ft)
<br />p
<br />UN 29I Regulated Medkai Waste, n.o.s.,
<br />T014 — 44 Gal Tub (Bio) (5° 9< cu ft)
<br />AUTOCLAVE
<br />Q
<br />UN3201 Regulated Medical Waste, n a.s.,
<br />6,2, PG16
<br />M (2.7 Ed
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<br />W
<br />W
<br />UN8291 Regulated Medial Waste, nos,
<br />6.2, PGIl
<br />TP1S — 20 Gal Tut' 4Path) `2.7 cu ft)
<br />6 P6iI Regulated Wasie, n.os.,
<br />TY.15 —20 Gal Tub (Chem*) (2_7 cu ft,)
<br />UN3291 Regulated Medial Waste, n.o.s.,
<br />6,2, PGII
<br />-. . _ 83.asystems trurdboard gix (4-7cu tt)
<br />6 ll Regulated Medial Waste, nos.,
<br />Phai maceut icxal Wast
<br />teneratoes, Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS 111,
<br />oribed above by the proper shipping name, and are classified, packaged, marked and labelleatpfacarded, and
<br />In all respects In proper cooed' it�tan for transport according to applicable international and national governmental r/eaulaho "
<br />4. TRANSPORTER 1 ADD
<br />SfcCycle, XaC. This as a Thxeu:gh Jltd:p netst
<br />4135 W. Swift: St
<br />0 Ycenn.o, CA 93722
<br />a
<br />�
<br />TRANSPORTER CERTIFICATION: ReceEpt of medcai waste as deacnbe'�''�_...--^'��
<br />8. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS:
<br />oa
<br />9
<br />Eli INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of madxal west® as described above.
<br />Prtnt/7ype Name Signature
<br />cry,. I S.INTERMEDIATE HANDLER S/TRANSPORTER 3 ADDRESS:
<br />20. NO. or 2D. VOLUME
<br />CONTAINERS
<br />® ZIJ--
<br />Phone #: k0*!f) c fa—.t1Z1
<br />Applicable Permit Numbers:
<br />8au%l: Reg# 3400
<br />Date _
<br />Phone 0:
<br />Applicable Permit Numbers:
<br />Data
<br />Phone 0:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER f TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pdnrlype Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />d rs, on 1i to : NOM Sd Lake, UT
<br />QSA. tmstgnated Fadgty: so, Alternate Facility: (] 8C. Alternate facility: 8D.Attemate Facility:
<br />U
<br />cede, Inc. , Inc. ftdcycle Inc.
<br />4136 W.e.Inm
<br />SM t IINOM110OW49 1561 Shaft DW4 2775 E! St
<br />FMsn*,CA S$722 North ul a, UT r, CA sm Vemon, CA 90058
<br />M 276-1121 ($Qty 9iM1665 (831) $30.1098 (31M 8132.8000
<br />,TWOST22 TS/t W as TWOST-26 '
<br />AUTOCLAVE
<br />TREAMM8111MIEORTErtify thal I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above Indicated wastes n accordance with the requirement outlined in that authorization.
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<br />Pr1n pe 2 12 013 Signature Date
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