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+ MEDICAL WASTE TRACKING FORM NUMBER <br />.-®® Stericycile' IN CASE OF EMOR13ENCY CONTACT: CHEMiREC 1-600-4249300 STANDARD MANtFEaT 001-10-0-M <br />®4 fmied2r-* Rist' Route .9: 100 — 2'5 CUSTOMER NO. 21132 r4nFftganvxc <br />1`. Genbrator's Name, Address.and Telephone Number <br />866Nt <br />! f <br />WALTTE'0R4�pA'1I TsCiLIL& <br />161.7 1 CALT-rC I' III& ST <br />STOCKTON, CA 95204 61.17 <br />(289) 148-6435 7/30/2613 <br />CUSTOMER NUAWR 6039652-002 GENERATORS REWMATicet# <br />2A. DESCRIPTION OF WASTE 28. CONTAINERTYPE <br />20. NO OF <br />2D. VOLUME <br />UN3291 ReNlated Medical Waste, n.o.s., <br />62. PGII TWS - 40 Gal Tub (8i0 (S.3 en ftp <br />CONTAINERS <br />Cu Ft <br />UN362, 61Ii Regulated Medical Waste, att.d., 2849 _ 37 Gal Tub M0 (4.9 r.v ftp <br />Cu Ft <br />O <br />&2PGII Regulated Medical Waste, n.o.s., T814 - 44 GAIL TUb (83.ra) (S.9 CU ftp <br />CU Ft. <br />UN3291 Regulated Medical Waste, n.o.s., T821 — 20 Gal TUb (13io) (2.7 Ou ftp <br />6.1„ PGti <br />C„ Ft <br />SA li Regulated Medical Waste, n os., TP15 - 2>7 Gal Tub (E'a1~I1 (2.7 cu f>~) <br />Cu Ft. <br />-6'T%II Regulated Medical Waste, n.os,, TY15 — 20 Gal Tub (Chemo) 42_7 att ftp <br />Cu Ft <br />UW29t Regulated Medical Waste, n.o.s., <br />6.2, Pell KRB_ -- Biosystems Catdhoard 13oX. (4.2 cit ftp <br />Cu Ft <br />UN3201 Regulated Medical Waste, <br />62, PGII <br />Cu FL <br />Phama'ceut3ca3 Zt. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS Illip- 0 Cu Ft <br />described above by the proper shtpping name, and are class111ed, packaged, marked and labsued/placarded, and <br />era In all respects Inproper condition for transport according to applicable internationaland national o " <br />ve io s. <br />PsP 9 PP9 t <br />c <br />Kpq!ttd Name Signature Date 7/30/0 <br />4. TRANSPORTER 1 ADDRESS Phone #: (559)2f5-1121 <br />Stei_ibycle, Inc. This is a ThS C3 hipment Applicable <br />Permit Numbers, <br />41.35 A. Swift Ave <br />Haulet: Rag# 3400 <br />FL'esno,CA 93722 <br />a <br />TRANSPORTER CERTIFICATION; Receipt of medical waste as described above. <br />Prtri mpeName Signature Date <br />S. INTERMEDIATE HANDLER 2 MANSPORTER 2 ADDRESS: Phone #: <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as descrdted above. <br />Pdnt/T Name Signature YPe gn Data <br />S BNTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone # <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medtml waste as described above. <br />121 <br />Pnnt/'typs Name Signature Date <br />7. DISCREPANCY INDICATION <br />Transferred =Wrlti cu A to : North Sok Lake, tiTP <br />_ <br />'i <br />Q 6A. Designated Facility: <br />n is. Altemate Facility; ® ac. Altemate Fadnty: ® 81). Alemete Facntt . <br />Sbftdle.Inc. <br />SYartcyde.Inc. Stertcygle.Inc.Steiicyde.Inc. <br />a <br />4135 W. SMIIANO <br />90 North Fo) t m Or 1551 Sh*10111 DIWO 2775 E. 2M St, <br />u. <br />Fresno.CA 93722 <br />Notch Sal Lako', Ur E4051 H091St>3F', CA 315023 Vemon, CA 80058 <br />(659) 275-1121 <br />t809938 -1m (93t) 83Cw098 (323) 362 80ttD <br />3"$J"s TWOST 83 TSIOST 26 <br />IXFWNVE <br />I <br />DALE ANNE ORTIZ <br />oil <br />= <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 />h received <br />t otbn lad wastes i <br />accordance With the requirement outlined in that authorization. <br />Pdnt/iWm Name 3 GG�I jj� <br />Signature Date <br />