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MEDICAL WASTE TRACKiNQ FORM NUMBER <br />E !® Sterirycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-424-9300 BTANDARO MANIFEST 001 -10 -08 -STD <br />®®® tee�d:greootesedxMgaa• Route 'f: 100 26 CUSTOMER NO. 21132 1t4DFROODUE7 <br />1. Generator's Name, Address and Telephone Number <br />ATTN. <br />CALXVCVK2k 2RS101CAL FAC:ZL%TY <br />161.7 'N CALIFORIMA ST <br />STOMMN, CA 95204- 5117 <br />', lli';IIIILI!GI!�IIIP1IJLill <br />(209) 948-6435 <br />GENEMIOR'S RMSTIMMON 8 <br />6,/18/2013 <br />2A. DESCR1FnON OFWASTE <br />2S. CONTAINER TYPE <br />20. NO. OF <br />2D. VOLUME <br />S 23Ii Regulated Medial Waste, mos,„ <br />TBil'S - 44 Gal Tab {t33.a} {5_3 cu ft)CONTAINERS <br />S doyde, Inc.r <br />kic. <br />SDe ;y�e, Inc. <br />W. <br />Cu Ft. <br />UN 2291 Regulated Medial Wash n.o s., <br />T049 - 37 Cal, Tab {B 0 {4.9� au ft} <br />tr, <br />Fm9na,CA 83722 <br />NO* Sol 1.11100, tat° <br />WNW, CA SSW <br />Vernon, CA =68 <br />Cu FL <br />6N, 29iPGJRegulated Medical Waste, n.o.s., <br />- 44 Ga 'Pab {$io} (S.9 Cu. ft} <br />(831) <br />� $62.6000 <br />Ft <br />UN3291. Regulated Medial Waste; n.os., <br />4 - Cu.6.2, <br />PGH <br />to Ft. <br />� Regulated Medical Wash, n.os., <br />� <br />TPAS 20 Gal Tub (Path) (2,7 cu ft) <br />I ave been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />caordanea with the requirement outlined in that authorization. <br />nntRy�eNam 4-f+7 <br />Signature <br />Cu Ft <br />6.2, PGH Regulated Medical We*, nos., <br />TY18 - 20 !gal Tub (Chem*) 42.7 cu ft ) <br />Cu Ft <br />4JN3291 Regulated Medical Waste,n,os., <br />6,2, PGI <br />KRB - af.asystems Cart1board t3�ox {4.2 ft} <br />Cu Fe <br />UALLR291 Reguleted Medial Waste, n.o.s„ <br />6.2, PGII <br />Cy FL <br />Pharmaceutical Waste <br />Cu Ft <br />3. Generator's Certification; 'I hereby declare that the contents of this consignment are fully and accurately <br />raven k—1 nhn�n M. !ho mm�ar chinninn nnmm .—I e—A ... —1 nonL�nnrt mer4ed —4 lal.ee®AA.fer.erl...! ...,.1 <br />Tt3TALS <br />are In all respects in prc�paicondltliiq for VaZrport according to appllcabie intergattenal and nahonai ental regulations.” <br />I Pdnted%p Name Stgnatun#1 <br />a 4. TRANSPORTER 1 ADDRESS <br />Ster 'cyclt�, Ittd. This 3,s a Through <br />4135 V. SWi.£t: Ave <br />reennoaCA 93722 <br />a <br />TRANSPORTEF C RTIFIC/AJTiON: Receipt of medical waste as described above <br />PrtnVlype Name ►ti -C'IZ Slanalure <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 <br />Phone 8: t OSi f9-7 i;d� <br />Applicable Permit Numbers: <br />Hauler Regif 3400 <br />Date <br />Phone N. <br />AppHoabla Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdriMps Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER $ ADDRESS: Phone 6: <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER ITRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrtnIt ype Name Stanature Date <br />8 Designated Facility: u 89. Alternate Facility: <br />® 8C. Attemate Factlity: <br />® 81). Alterlate Facility$ <br />Stericycle. inc. <br />4136 Avre <br />S doyde, Inc.r <br />kic. <br />SDe ;y�e, Inc. <br />W. <br />SO NOrtt111OO West <br />1661 n lulus <br />27761y. 20 St, <br />tr, <br />Fm9na,CA 83722 <br />NO* Sol 1.11100, tat° <br />WNW, CA SSW <br />Vernon, CA =68 <br />276-1121 <br />(001) <br />(831) <br />� $62.6000 <br />y1096 <br />AUTOCLAVE <br />q� 2Ti <br />TREA ACi�: IOtcert) that I <br />received the 'a1111bove tndirqc}at�g� wastes in <br />I ave been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />caordanea with the requirement outlined in that authorization. <br />nntRy�eNam 4-f+7 <br />Signature <br />Date <br />