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0 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />Sterlcydw IN CASE OF EMERGENCY CONTACT: CHEMTREO 11-800424-9300 <br />STANDARD MANIFEST 001-10-00-M <br />Roitte IF: 100 - 24 CUSTOMER NO. 21132 <br />14DFROODY3Z <br />1. Generator's Name, Address and Telephone Number <br />ATTU.- <br />CALTYCRMA MEDICAL IMMLITY <br />1617 71 COIL CMUA ST <br />nxmu, cak 45204- 6117 <br />(209) 948-6435 <br />7/16/2013 <br />CuortimEn Numeren 6039652-002 GENERATORS REGISMMON <br />2A. DESCRIPTION OFWASTE 28. CONTAINERTYPE <br />20. NO. OF <br />go. VOLUME <br />UN3291 Regulated Medical Wage, P.o s., Ta*5 - 40 Gal Tub (Iat*o) (5-3 = ft) <br />&Z Pell <br />CONTAINERS <br />Cu PL <br />UN3291, Regulated Medical Waste, nos., TH49 - 37 Gal Tub Mo) (4, 9 Cu. tt) <br />0.2, Pell <br />Cu Ft <br />x <br />UN3291 Regulated Medical We*, rhos., T014 - 44 Gall Tub (Bio) 15.9 Cu 't)0 <br />6.2. 11111 <br />CU Fl. <br />UNMI Regulated Medical Was% O.O.S., TB23. - 20 ell.Tub(Via) (2-7 au ft) <br />0.2, PGII <br />Cu Ft, <br />UNS291 Regulated Medical Waste, n.o.s.. TPIS - 20 ,Sal Tub (path) 42,7 Cu rt) <br />6.2, PGII <br />Cu Fl. <br />UN3291 RogulatedMadicalWaftri,o.s., <br />0.21 PGII TY15 - 20 Qa:L Tub t0unco) (2-7 Cu ft) <br />Cu F1 <br />UN3201, Repulatod Medical Waste, nmx., <br />'aliosystems Cardboat-d Voy- (4-2 cu -ft) <br />62, PQIf <br />Cu PI <br />UN3291 Regulated Medical Waste, n.ox, <br />6.2. Pall. <br />Cu Ft <br />ti <br />PhaLmacoucal Was" )d <br />A <br />CU Ft <br />3. Generator's Certification: 01 hereby declare that the contents of this consignment are billy and accurately TOTALS <br />Cu Ft <br />described above by the proper shipping name, and are classified, padcaged, marked and labelled/placarded, and <br />are In all respects In proper ciondfilonJor.1cansport. aroorcring to app Is intemattonat and national gave 9 akwistions? <br />V,!� rA AA 107" - <br />113datodnYped T7 <br />r <br />Name signal i <br />D, <br />4. TRANSPORTER I ADDRESS., <br />Steniclyale, Inc. 0 This is a Through SUpme 9, <br />Phone <br />413S X. Swift ?L70 <br />Applkable Permit Numbers <br />Hauler Reg# 3400 <br />Freano,M 93722 <br />TRANSPORTER CERTIFICATION* Receipt of medical waste as described above. <br />PrinittlYpe Name—Signature <br />a <br />S. INTERMEDIATE HANDLER 2 MANSPORTER 2 ADDRESS: Phone 0: <br />Applicable Permit Numbers - <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, <br />Printrrype Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS* Phone N <br />Applicable Permit Numbers, <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described abom <br />PrInIfTypa Name Signature Date <br />7. DISCREPANCY INDICATION <br />Tmnsfaffed containers, _ ou A to * Naft Salt Lake, UT <br />n 8A. l3ealgantod facility. <br />819. Allemate Facility. 0-86. A—Itemate Facility: So. Attemate Facility. <br />suftoe. Inc. <br />swq-de, Inc- swcoo'hic. <br />I= <br />Q <br />I <br />4 ISS W. SVC AVO <br />90 North F10dioro Or 116511 sheblix Orw <br />2775, .213th St <br />u. <br />PresnoCAS3722 <br />North Salt Lake, Ur W54 Hollislar, CA OW <br />Vernon, CA 90058 <br />(569) 275-1121 <br />(801)MISSS (83I)630-10.96 <br />(323j862- 3000 <br />TAWRAVE <br />RIF <br />3A4484"S TS(= 83 <br />T8110ST-26 <br />DALE ANNE ORTIZ <br />TREATMENT FACILITY. I certify that <br />I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received wastes I <br />i accordance with the requirement outlined in that authorization. <br />%rbilMd <br />Prldqype Name <br />—Signature Date <br />ORIGINAIL <br />J <br />