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0-0 <br />S#ericyCte' IN,:ASE OFMEHGEd CY <br />•®* trot«e�regaeaea�tgerst: Itf3JU:e : IOU — <br />1. Generator's Name, Address and Telephone Number <br />ATTN-. <br />CALIFCtRNIA XMICAL 'FACILITY <br />261.7 'N CALILMMA ST <br />STOCKW10, CA 962114- 6117 <br />MEDICAL WASTE TRACKtNG FORM NUMBER" <br />CHEMTREC i-800.424-9300 STANDARD MANIFEST oo1-1104$-8To, <br />CUSTOMER NO. 21132 MI)FRf30i3i/SA <br />Aunsiomu'uiiiNeui�iuuiuii <br />t269) 9148--6435 <br />3. <br />CuMMiRNUMBeR 6039 652-002 � <br />i <br />amRraReoWRA*nDN# <br />® 8C. Alternate Facility: <br />2A. DESCRIPTION OF WASTE 20• CONTA <br />ERTYPE <br />62.2911 Regulated Medical Waste, n.o s., TBOS — 40 Gal Trsb (Bio) � <br />3 �c a J:t) <br />stat Inc. <br />4135W."Ave <br />90 NOM 1100 Wass <br />UNS29111 Regulated Medical Waste, n.o s., T849 — 37 tial Tub i81ou a <br />PGIi• <br />ttf <br />. ext62, <br />it <br />U �) Regulated Medical waste, n.o.s., TB1 — 44 Gal Tvb ( <br />cxk %ty- <br />Hollister. CA 9SC123 <br />62, <br />(M) <br />F <br />kt <br />I' Regulated Medtcai Waste, mos., 26 <br />GIA ft) <br />I=) 3000 <br />W <br />W <br />UN3291 Regulated Medical Waste, nos.. F — 20 Gal Tub ilpatll)ou <br />8.2. PGI) <br />i <br />6 PCr4 Regulated Medical Waste, mo.s., TY1S - 20 Gal Tub 4chemol 1113.7 ot.t ft) <br />6UN 91 Regulated Med€cai Waste. mos., MM — 83.o stems; CardbojW Box (4-2 4 <br />palUN3291. <br />_ <br />Regulated Medical Waste, n o s . 1 a- <br />3. Generator's Certification: `I hereby declare that the contents of this consignment re fully and accurately TOTALS 10- <br />I described above by the proper shipping name, and are classified, pacicaged, marked Ind tabelle#lacarded, and <br />are In all respects In proper condition for transport aocording to ap bfe intematk and national govemM- <br />4. <br />ne <br />t _ tPrinted%ved game ff=i!2 1 Signature <br />TRANSPORTER 1 A el S: '• <br />e> aeycZe, Inca. Tt is a Thcoxvh Stripmeut <br />0 4136 W. SWift Ave <br />90 Feeano, f.CA. <br />y" <br />(� TRANSP"ERRFICATION: Receipt of medicalwaste as described abov�.PdnVIS"pe NSignature5. INTERME2 / TRANSPORTER 2 ADDRESS: j <br />�g t <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recei . of medical waste as described above. <br />PrinMiype Name Signature " <br />6/26/2013 <br />2C. NO. OF 12D. VOLUME <br />CONTAINERS <br />r� <br />Phone #: 147+.1: , G tit"iJl4J <br />AppfIMU9 erV' mbe__,Is�3400 <br />Jdau ei 1�E9 <br />6� <br />Data <br />Phone #. <br />Applicable Permit Numbers: <br />Data <br />S. INTERMEDIATE HANDLERS /TRANSPORTER 3 ADDRESS: I Phone #: <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recerpit of medical waste as described above. <br />PdnVW8 Name Signature t Date <br />7. DISCREPANCY INDICATION Thantermd cor"I t@m i CU a to Nt th Sall Lake. UT <br />8A. Designated Facility: <br />® 813. Alternate Facility: <br />® 8C. Alternate Facility: <br />❑ 80. Altamate Facility: <br />S micycle, Inc. <br />Stericycle, Inc. <br />I Sb t <br />stat Inc. <br />4135W."Ave <br />90 NOM 1100 Wass <br />Oliva <br />E 26 <br />St <br />FresW.GA 93722 <br />North Salt Laker UT 840% <br />Hollister. CA 9SC123 <br />Vernon, CA 90058 <br />(M) <br />(88I)931i-lass <br />i 18311630.1098 <br />I=) 3000 <br />I.A-448%Jt 6 Tskwaa TWOST=26 <br />AUTOCLAVE <br />DALE ANNE ORTIZ <br />'MENT FACILITY: I certify that have been authorized by the appii $ bfe state agency to accept untreated medical wastes and that I have <br />d tkl ove�i icattted wastes i accordance with the requirement o�ttitned In that authorization. <br />101 <br />aName G• —Signature ffI Date <br />r <br />