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`MEDICAL WASTE TRACKING FORM NUMBER <br />� A Stericycle• IWSE oP MEjW! C jn. CHEMTREC 1 -SOD -424-8300 STANRARD MANIFEST Dol -10 -06 -STD <br />•.• F"toc ha* fttoftw�: it�'!?U 1LI[i — ; 1 CUSTOMER NO. 21132 14DFROODTGD <br />1, Generator's Name, Address and Telephone Nyumber <br />A64[: <br />� <br />QpTirM*"& M J•if»F b <br />166--1.7 3t CAbIFORIUA ST <br />STOClc1'ON, CA 95204- 61.1.7 <br />(209) 948-61435 6/1.1/2013 <br />CusToMERNUMBER 6039652-002 GENERATOR'SREM7nATM <br />2A. DESCRIPTION OF WASTE <br />26. CONCAINERTYPE <br />20. NO. OF <br />2D. VOLUME <br />UN3291 Regulated Medial Waste, n.os. <br />91 <br />%VM — 44) tical. Tab (13io� (5_3 Cut t4t) <br />CONTAINERS <br />I <br />FGII <br />Cu FIL <br />UN3291 Regulated Medical Waste, n.o.s., <br />T849 - 37 Gal. Tab (Eio) (4.9 'Et) <br />6,2, PGiI <br />Cu Ft. <br />cc <br />UN3291 Regulated Medical Wash, rias., <br />T81.4 - 44 Gal Tub (Rio) {5.9 cu tt $ <br />® <br />6.2, PGII <br />CA R. <br />RUN3291 <br />Regulated Medial Waste, n.o.s., <br />za - cu <br />Cuff <br />LU <br />UNU91 Regulated Medical Waste, nos., <br />FGII <br />TPI S - 20 982 Tab Wath) 42.7 CAI ttc3 <br />W6.2, <br />Cu FL <br />UN3291 <br />2, PGII Regulated Medical Waste, n.0's., <br />T1d'.t5 - 20 'tel Tub ¢Clieraa3 t 2.7 cu ft) <br />Cu Ft. <br />1 <br />UN3291 Regulated Medical Waste, n.o.s., <br />t t �,r�3yst Cardboard 13ox (4-2 ,a ft) <br />6,2, PGII <br />Cu Ft <br />UNNS291) Regulated Medical Waste, n o.s., <br />(/' V <br />Cu FL <br />Pbas=4cautical, Waste <br />Cu F <br />3. Generatoes Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS CU FL <br />described above by the proper shippping name, and are classified, packaged, marked and labelled/placarded, and <br />a»rdtng to applicable Ince ahonat and national governmentaleg Is Inns" <br />are in all respects In proper �nditton for trsF.4�n <br />/®421 Y <br />(Prtnted/typed NameSignatwu Date <br />4.TRANSPORTER1ADDR" : P e# t <br />Stier byCle, xno. This -i s a ThroiVh shipment <br />cable tNReg#s:3400 <br />4135 V. Swift AireA Hauler <br />a <br />Ft-•r_aSno,CA 937.22 <br />a <br />TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above <br />Printtiype Name Signature Date <br />,. <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone fl: <br />N <br />N, <br />Applicable Permit Numbers: <br />RIC <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Pdnnpe Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: . Phone # <br />Applicable Pam -it Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />91 z <br />— <br />Pdrittrype Name Signature Date <br />' <br />7. DISCREPANCY INDICATION <br />Transfermd collukkers, cu 4 to = North Sak La)*, UT <br />® 8A. DWgnaled Facility: <br />8H. Alternate FaciOty: ❑ 8C. Alternate Factlity. ❑ 8D. Alternate Facility: <br />_iC <br />ricycie.lrtc. <br />Ster%tde. Inc. .Inc. $t&gde, Inc. <br />413E W. SM AVe <br />90 "Or h 1 tt34 Wast 1551 Drive 2ic75 , 26th St <br />UT 84438¢ <br />(325) <br />(WSJ 2755-1121 <br />(8e011) gro- 585 (83)00-1k $62 3Il00 <br />U1 <br />TZO= <br />M448-JA46 TAT 83 TWOST-28 <br />AUTOCLAVE <br />TREATMh�Qp��"MIART19MIfy that <br />I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />ti <br />received Indicated wastes i <br />accordance with the requirement outlined in that authorization. <br />�tjh�e�(�above <br />112013 <br />Pdnt/jype NJW <br />Signature Date <br />