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<br />*00 Stericycle•
<br />• ,mYcdnprcopio e.dade�a
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-000.424.9300
<br />Route #:t 100 — 24 CUSTOMER No, 21132
<br />MEDICAL WASTE TRACKING FghM NUMBER
<br />STANDARD MANIFEST 001 -110.06 -STD
<br />M®FROOFISY
<br />OFtIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />A�>i:1111111111111111111111111111111111
<br />CALIFMVIA MEDICAL FACILITY
<br />1617 N CALIFORNIA ST
<br />STWMN, CA 95204— 6117
<br />t09j 946-6435 6/1312613
<br />t
<br />6039652-002
<br />GE16TOMER NuMBEn GErtarrATotrs REGISTRAttoN �
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINERTYPE
<br />20. NO, OF
<br />2D. VOLUME
<br />Ufd329t, Regulated Medical Waste, n.os.,
<br />x1305 .. 4q �, Thy (13.4) (S.3 an ft)
<br />CONTAINERS
<br />6 .2, troll
<br />Cu Ft.
<br />UN3291
<br />6.z2,, GiiRegulated Medical Waste, n.cs.,
<br />T849 — 37 Gal Tub (Bio) (4, 9 cut Lt)
<br />Cu Ft
<br />D:
<br />UN8291 Regulated Medleai Waste, n.os,,
<br />TB14 — 44 Gal Tub(Bio) (3.9 cu i t)
<br />0
<br />6,2, pelf
<br />Cu R.
<br />tom'
<br />UN3291 Regulated Medical Waste, n O.S.,
<br />6.2, poll
<br />o) (2.7 an
<br />�
<br />Cu Ft
<br />1L
<br />UNS291 (Regulated Medical Waste, nA s
<br />19 PSIi
<br />TP15 — ZO Gal Tub (Path) (2.7 cu try
<br />Cu Ft
<br />Ctj
<br />6.NNS291i-Regulated Medical Waste, n.as.,
<br />Tr S — 20 Gal Tub (Chemo) (2.7 cit ¢t)
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, nos.,
<br />6.2, Poll
<br />— Biosystems Cardboard Box (4.2 cu ft)
<br />Cu FL
<br />UN3291 Regulated Medlgl Waste, n.os .
<br />6.2, PGIi
<br />Cu FL
<br />Pharmaceutical Waste
<br />Cu EL
<br />3. Generator's Cer46icaUora "I hereby declare that the contents of this consignment are fully and accurately TOTALS 10- Cu FL
<br />described above by the strippping name. classified, marked and labeiled/placarded;
<br />proper and are packaged, and
<br />are In al respects In proper condition tar traewport according to applicable International and national governmental regulations."
<br />1 iPnntediTyped ?ff/_ .0!0
<br />Name Signature Date
<br />4.TRANSPORTER 1 AD��ESS .hate#: 2 a-1121 °
<br />eriCyC e, Ina. this is a Through Shipment Phone,#:Permit
<br />4135 W. Swift Ave able Numbers:
<br />,a
<br />Hauler # 3400
<br />Reg
<br />Irrecno,CA 93722tc
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described
<br />'� y�
<br />PrinUiype Name Signature Date
<br />e
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #:
<br />ea
<br />Applicable Permit Numbers
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printrlype Name Signature Date
<br />B. INTERMEDIATE HANDLER 31TRANSPORTER 3 ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />R11
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />—z�
<br />Pdntlrype Name Signature Date
<br />7. DISCREPANCY INDICATION Trwisbned its, eu 0 to Noflt W LAW, UT
<br />® BA. Designated Facility: [] 86. Attamata Facility: ® 8C, Alternate Facility: 0 SD. Alternate Facility:
<br />Staricyde.Inc. Stm4de, Inc. Sterlcycie, Inc. Stericycle.Inc.
<br />v
<br />4136 W. SM Av$ 99 N. F06om 0M 1661 st abn DrIft U76 E. 20 St;
<br />4
<br />Pmno.CAM722 Narth . UT' 84 M 0, 4 Haller, CA 35023 Vtttmon, CA 80068
<br />(659) 276-1121 (801) 1365 (831) G-1098 I=) 362-3000
<br />TSt 2 6 Takwas TSJ09T-26
<br />AUTOCLAVE
<br />t,
<br />t�I
<br />TR AVP*Lam- :;Toertify 11 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 s in accordance whit the requirement outlined In that authodzatton.
<br />QU J Signature
<br />PrfO
<br />er Date
<br />OFtIGINAL
<br />
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