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® MEDiCAI.WASTETRACKINGFORMNUMSER <br />®° 5ierFcytie' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-900.4249308 STANDARD MANIFEST 001.10.0SM <br />•.• r�rarmr�nrratia�gRhk Route 9: 100 -- 28 CUSTOMER NO. 21132 MDFROO92PB <br />1. Generator's Name, Address and Telephone Number i <br />ORWA 14EDXCAL rMILITY <br />1617 N CAMFORMA ST <br />STOCKTO'N, CA 96204— 6117 <br />(209) 948-6435 8/2412013 <br />GE NenATOR'S RErns UMN # <br />2A. DESCRIPTION OFWASTE 90. <br />COMAINERTYPE 20. NO. OF <br />2D. <br />VOLUME <br />UN329f Regulated Medical Waste, ri.oA, <br />CONTAINERS <br />9D.Attenlate Faclilty: <br />9.4 PGII. <br />T805 - 40 Gal Stub (Bio) f5.3 au ft) <br />Cu Ft. <br />UN3291 Regulated Medical westa, n.as., <br />6.2, FGIi <br />TB49 - 37 Gal 'Tub (Bio) (4.9 cu ft) <br />1661 Sheibatt Drt" <br />Cu Ft. <br />1� Regulated Medical Waste, n.o s., <br />6.21PG <br />TB14 ^ 424 Gal Tub (Bio) (5-9 Cu tt) <br />North Salt Lako, UT 84 05- Oi <br />4 Holllsbar, CA 95023 <br />Vernon. CA 90056 <br />Cu FE. <br />23Poli Regulated Medteal Waste, n.os.. <br />T821 - 20 Gal Tub(Bio) (2.7 au ft) <br />(323)362-3000 <br />$A -448%W38 <br />TS(OST 83 <br />Cu Ft. <br />623PGaReguetedMedical Waste,n.os., <br />In accordance with the requirement outlined In that aufhorizabon. <br />TP1S - zo aal Tub (Path) (2.7 cu ft) <br />Gu Ft <br />1.11113901 Regulated Medical Waste, nm.%, <br />6.2. PGII <br />TY15 - 20 Hal Tuts (Chemo) ($.7 au ft) <br />Cu R. <br />UN �I� Regulated Medical waste, mos, <br />KRB - Riossty Cardboard Bax f4.2 Cut fit <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGI <br />Cu Ft <br />PharmacieUta.cal Waste <br />Cu F€ <br />3. Generator's Certification: I hereby declare that the contents of this consignment are fully and accurately <br />TOTALS 111► <br />described above by the ormar shinnlnn names. And ate rJar_al6arf-: nankanaH marfeM And IahallariMiae.am4ert and <br />Cu FL <br />are In all respects In proper condition for transport according to applicable international and nalonal governmarge <br />IxPrinted/Typed Name ®� Signature <br />4. TRANSPORTER 1 ADDRESS: <br />}, Stecicyale, Inc.. EjThis is a Through <br />4135 Q. Swift Ave <br />BCean4,CA 93722 <br />Il TRANSPORTER CERTIFICATION: Recelpt of medical waste as describedabffm <br />-ICt ,,y <br />PrinIffte Name k "!C smnature <br />6. <br />2 /TRANSPORTER 2 ADDRESS: <br />Ily Date .- Zai, <br />\Pixme #: (559) 275^1123. <br />AQpticabie Permit Numbers: <br />Hauler; Reg# 3400 <br />fee, <br />-��• <br />Date <br />Phone If: <br />Applicable Permit Numbers <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Rewilitof medical waste as described above <br />Pdwlvpe Name Signature Date <br />U. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Reoelpi of medical waste as described above <br />Pdnfllype Name Signature <br />A L UUM1'ANU'Y INAICATION <br />the above Indicated <br />JI+12 0 2013 <br />Phone #: <br />Applicable Permit Numbers: <br />Date <br />'transferred I conitabiem, <br />® 8A. Designated Facility: <br />Stericycle, Inc. <br />4136 W. SMAVe <br />Fresno,CA 93722 <br />(959)275-1121 <br />the above Indicated <br />JI+12 0 2013 <br />Phone #: <br />Applicable Permit Numbers: <br />Date <br />'transferred I conitabiem, <br />rel ft to : North Sa8 Lake, UT <br />88. Alternate Facility: <br />® 8C. Alternate Facility <br />9D.Attenlate Faclilty: <br />Sterlcycle, Inc. <br />St+edcycle, Inc. <br />Stericycle, Inc. <br />90 N. Foxboro Drhre <br />1661 Sheibatt Drt" <br />2776 E, 20 St <br />North Salt Lako, UT 84 05- Oi <br />4 Holllsbar, CA 95023 <br />Vernon. CA 90056 <br />(801) 938.1555 <br />(831) 63tI-1098 <br />(323)362-3000 <br />$A -448%W38 <br />TS(OST 83 <br />TWOST 26 <br />t I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />In accordance with the requirement outlined In that aufhorizabon. <br />