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ftericy, <br />je <br />w <br />0 MEDICAL WASTE TRACKING FORM NUMBER <br />IN CASE OF EMERGENCY CONTACT: CHIEMTREC 1-800-424-0300 STANDARD MANIFEST 01-10-084TO <br />]Route #: .100 - 27 CUSTOMER NO. 21132 MDFROO83L2 <br />1. Geliirator's Name, Address and Telephone Number <br />ATTN., III ! I I� I I� I 1 <br />CALnrcmax NEDICAL MWILITY <br />1617 1 CALILPCMA ST <br />STOCWMN, CA 96204- 6117 <br />(209) 948-6435 9/27/2013 <br />CusTomm NumsEn 6039652-002 GENERAMS REGISMAIDON 0 <br />2A. DESCRIPTION OFWASTE 28, CONTAINERTYPE <br />2C. NO. OF <br />2D. VOLUME <br />ON3291 Regulated Medial wage, n.os,, TBOS - 40 Gal Tub (Bio) (S. 2 cru ft) <br />CONTAINERS <br />62. M1 <br />Cu Ft. <br />UN3291 Regulated Medical Waste, Lo.s,, TO49 - 37 Gal Tub (Rio) (4.9 cu. ft) <br />6.2,P8111 <br />Cu FL <br />It <br />U2 , Regulated Medical Waste, mo�L. TB14 - 44 Gal Tub (Bio} (S. 9 au. tt) <br />0 - <br />PGI1 <br />6T9 <br />Cu Ff. <br />rg-- <br />UNS291 TM -Gal - 20 Gal Ta(aio) 12.7 Cuft) <br />&?, PSI, Regulated Medical Wade. Los, <br />Gu Fl. <br />U1 <br />UN3291 Regulated Medical Waste, Los., TPIS - 20 Gal Tub (Path) (2.7 cu ft) <br />PrA <br />W6.2, <br />Cu 11 <br />UN3291 Regulated Medical Waste. n.oA. <br />6.2. pall., TY15 20 Gal Tub (Chem*) (2.7 cut ft) <br />Cu Ft <br />UN3291 Regulated Medical Waste, Lo's., <br />&2' PG11 MW Biowstems Cardboard Box (4.2 Cu ft) <br />Cu Ft <br />UNS291 Regulated Medical Waste, LOS., <br />0.2, 11611 <br />Cu Ft <br />Phda7naCeut�adl iiia <br />Ou Ft <br />3 Generator's Certification: I hereby declare that the contents of this consignment are fully and accurate Cu Fl. <br />described above by the shlFpbg Jay TOTALS 11-I <br />hibefled/placard. <br />proper name, and are classified, packaged, marked and and <br />or <br />are In all respects In proper condition for transport according to applicable international and national governmental regulations." <br />PrintsedName Signature Date 0&7 1-3 <br />4. TRANSPORTER I ADDRESS: <br />Stericycle, Inc. This is a ough Shipment Phoneiif: <br />Applicable Permit Numbers: <br />413S W. Swift Ave <br />Freano,CA 93722 33auler Reg# 3400 <br />cc <br />IL <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as deserlmd above. <br />PdrilifType No= Re.*7 le, -ja Signature --Date_ <br />S. INTERMEDIATE HANDLER 2 (TRANSPORTER 2 ADDRESS- Phone 0. <br />Im <br />Applicable Permit Numbers: <br />01@29 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recept of medical waste as described ave. <br />PrTnVfta Nam Signature Date <br />8. INTERMEDIATE HANDLER 3/TRANSPORTER 3ADDRMS, Phone 0: <br />Applicable Permit Numbera, <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medcall waste as d=nbed above. <br />PdntlType Name Signature Data <br />7. DISCREPANCY INDICATION <br />Undmid - co kers, _ to R to : North Sal Lake, UT <br />>- <br />SA. Designated Facift <br />69. Alternate Facilltr. E] 80, Alternate Facility. So. Alternate Facility. <br />nilsterIcycle, <br />Inc, <br />Sbricycle, Inc. SurIcycle. Inc. SUIrIcycle, Inc. <br />all <br />4136 W. $MAW <br />90 N. F040110 Drka 115511 Shelton Ddo 2776 E. 2M Sk <br />U< <br />ff <br />FrannoCA93722 <br />North Sid La)%, Ur 84 05. (154 HdIster, CA 0M Vernon, CA 90058 <br />all <br />(669)276-1!121 <br />pat) sais-16M (831) 630A09B <br />U1 <br />Tsfogm <br />3A446 -.W39 T8109T 83 TSIOST-26 <br />AUTOCLAVE <br />, <br />Icc <br />IjPnritfT <br />&TAE:A"NWAtIfy that <br />I <br />I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />h -received <br />the above Indicated wastes 11 <br />accordance with the requirement outlined In that authorization. <br />AW 2 7 2013 <br />pe <br />Signature Date <br />