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e. MEDICAL. WASTE TRACKING FORM NUMBER
<br />•® SteriCyCle` IN CASE OF EMERGENCY CONTACT: CHGMTREC 1-800424.0300 STANDARD MANIFEST 001 -10 -CMD
<br />®.• rmtaitkaPa *taxa Route 0z 100 — 23 CUSTOMER NO. 21132 ` MI)FROODM E
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:l t 1
<br />CALMYCRIa2k t+ OIGAL FACILITY
<br />1617 V CAL,IFOR'IaA 3T
<br />STOCKTON, CA 95204- 6117
<br />(209) 948-6435
<br />7/9/2013
<br />CusromssNumseR 6039652-002 G94ERATOR'SREc,ISrRAMON#
<br />2A. DESCRIPTION OF WASTE 28. CONTAINERTYPE
<br />20. NO. OF
<br />21). VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />8.2,Poll T805 -- 40 Gal Tub (Bio) (5_3 cu 11t)
<br />CONTAINERS
<br />Cu FL
<br />1 F 1 Regulated Medical Waste, n s s, i
<br />6Z TB49 _ 37 Gal Tub (Rio) t;4 9 cu -Ity
<br />B,2, PGI/
<br />Cu R.
<br />p
<br />62 PGI/ Regulated Medical Waste, n o s„
<br />TB14 — 44 Gal Tub Mali (S. 9 snz ft)
<br />�
<br />.—✓
<br />Cu FI.
<br />Regulated Medical W
<br />llN3291 aste, mo.s.. TB21 ^ 20 real Tub (Bio) (2_7 cu ft)
<br />1611
<br />6.2,
<br />Cu FL
<br />W
<br />UN3291 Regulated Med ca Waste, n.os.,
<br />PGII WP15 — 20 raa, Tula (Path) (2.7 Cu ft)
<br />Cu R.
<br />7 (78.2,
<br />U1113291 Ragulated Medical Waste, n.o s.,
<br />6.2, PGII TYIS — 20 Gal flub (Cheato) (2.7 Ca ft)
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, o o.s.,
<br />8.2. PGIl RF& — 19io:systems Cardboard Box (.4.2 ,cut -ft)
<br />Cu Ft
<br />Regulated Medical Waste, nax.,
<br />6N�32P,,
<br />Cu R
<br />Pharmaceutical Waste
<br />3. Generator's Corti icailon: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ►
<br />by and Isbelled/ptacardad, and
<br />e Cu Ft.
<br />deco lbed above the proper ah1 pin®Hama, are classified, packaged, marked and
<br />are In ail respects in proper co far transport according to applicable International and national govern latlons."
<br />Printe sd Norrie Signature
<br />Date"
<br />4. TRANSPORTER 1 ADDRESS.,r� Tia:t.s is a ThroWh shipment
<br />Phone #: (r589) 27$_1123.
<br />Steticycler Inc. E..1
<br />Appi able Permit Numbers.
<br />0
<br />4133 W. Swift Ave
<br />Hauled" Re:g# 3400
<br />Fresno,CA 337 2
<br />TRANSPORTER CERTIFICATION: R ipt of medical wasta as decc be)91A�
<br />"?
<br />e... 6 .. /3Pnnt/type
<br />Name t�" ignatureData
<br />—'fir
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />EliApplicable
<br />Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medwal waste as described above.
<br />PrinViWe Name Signature
<br />Date
<br />w u,
<br />6, INTERMEDIATE HANDLER 3 !TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />IN
<br />Appucable Parmlt Numbers.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recerpt of medical waste as described above.
<br />Printltype me Signature Date
<br />IS EPANCY INWATION
<br />Tmuf avid containers. t U 1t 10 : North Hak Lake,
<br />;8A,
<br />UT
<br />®,,,,,_,,,
<br />Designated vocurcr. 0 89. Altemate Faculty: 8C. Alternate Facility:
<br />El so.AItemete Facnity:
<br />ftricycie, Inc. Startcycle, Inc. Stertcyde. Inc.
<br />at dcycle, Inc.
<br />4135 W. 9Mft A" 90 Ndith Fentbab* Or 1 W 1 Shobn 000
<br />2775 E. 20 S!,
<br />Frasntt,CA 93722 North Salt take. UT W64 Hollister, CA 95623
<br />sermon, CA 90058
<br />X55' } 27F, -t t 4 (3111) SW/SGS (831)63CI-1098
<br />(323) 362 3MD
<br />W
<br />X22 3A -448,W36 T •s3
<br />TSIOS` -26
<br />AUTOCLAVE
<br />j
<br />TR IWIAfflZeertty t at I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above indicated wast in accordance with the requirement outlined in that authorization.
<br />r3 Signature
<br />PrinttFyf�l1ld 60 9 2013
<br />Date
<br />r fbtdt^G'G. r�rA6N4•
<br />12
<br />ORIGINAL
<br />
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