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®*- - - - - - - - - - - — - ME DICAL WASTE TRACKING FORM NUMBER 00 Stericycte` IN CASE OF EMERGENCY CONTACT CHEMED I -e00.424-9300 STANDARD MANIFEST 001 -10 -06 -STD ®. wstwaeW06 KW Rouge 0: 100 - 23 CUSTOMER NO. 21132 UnITRA(IMA 97 I We Name, Address and Telephone Number AT U., CALUOHIUA, MEDICAL FACILITY E I F !{ 16:17 I.CALIECIR111A ST STC1C14 611, GA 95204- 6117 CUSTOMER NUMBERUENERATows O REGISTRATION 652-002 2A. DESCRIPTION OFWASTE 2B. CONTAINERTYPE 2C. No. OF 21D. VOLUME (W3291 Regulated Medical Waste, mu., CONTAINERS 62, PSIl TE05 - 40 Gal Tub 13io S.3 cu ft Cu FL , P61 Regulated Medial Waste, n.o s„ TH49 - 57 Gall Tub (Bia) (4, 9 cu ft) 7. DISCREPANCY INDICATION Cu Ft 5,2 PG1i Regulated Medial waste, nos., TB14 - 44 Gal Tub (Rio) (S. 9 cit 'fit) h. ®SA t3oaignated Facility: 80. Alternate Fadilty [FOC. Alternate Facility.,[� 11D. Alternate Faci ty: Steticyde. ino. SterIcycie. Inc. Sterlaycie.Inc. Cu Ft. Regulated Medical Waste, mos, 21 TBtl - 20 GaZ Tub Moll (2.7 cu 'ft) 2775 E. 26th St 1, 6 PPGI� Vernon, CA SMSB w Cu FL Owl 6ii Aagulated Media! Waste, n.os„ TP15 - 20 Gal Tub )Fath) (2.7 alt ft) VE 8,lA�3ta TSIJCJST83 Cu Ft 2"PPsli nIlRegulated Medical Waste, n os., owC 6 TY15 - 20 Taal Tub (Chemo) (2.7 cu ft:) received the above indicated wastes I accordance with the requirement outlined in that authorization. Cu FL Ut+ts9291 f Regulated Medical Waste, n.o s„ ArbLm " 3 Z013 6,2r PGI I - 61a stems Caicdboar d. Bolt 4.2 cta ft) Cu Ft M21, II Regulated Medical Waste, n o.s., V1. 8U Cu Ft Pharmaceutical Welsher Cu FL 3, Generator's Certification: "t hereby declare that the contents of this consignment are fi lty and accurately An AUr A nfnm,.. ,n. Nu .aenawr nf.}nn..... nw.nn w A w.n wlww.wl.wA nwwbwwwA .nw.b..A wnA 1w1.wNw.tlwb.ww.AwA wwA TOTALS Cu FL ._._�_e. 000_0.__ �.._.��.._�r.-_e.�_--0000.. are In all respects proper condi on for transport according to appisoable lnternaflorfsa and natioraf g-ovemmental regulations. 1 t Printecirfyped Name Signature Date 4. TRANSPORTER 1 ADDRESS: Phone M. tx (559) 275-1121 Ste}:icycle, Inc. 0 This is a The 4135 V. Swift Ave SIT) j}1IIGTCl Applicable permit Numbers: a o Hauler Req# 3400 Fresno CA 93722 TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. tti P11wrype Nwm Signature Date /343 26�S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #: R9 V'- Applicable Permit Numbers INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, Pdntfiype Name Signature Date 6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS Phone #: Applicable Permft Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION. Receipt of medical waste as described above. PnnVTypo Name Signature Date 7. DISCREPANCY INDICATION Transferred t ontalners, eu ft to : North Sal Laka, UT h. ®SA t3oaignated Facility: 80. Alternate Fadilty [FOC. Alternate Facility.,[� 11D. Alternate Faci ty: Steticyde. ino. SterIcycie. Inc. Sterlaycie.Inc. Stedcycle, Inc. 4135 W SWtftAve so N. Foxboro O IVS 1561 Shilibn DrfYa 2775 E. 26th St 1, Fretano.CA 53722 North Satt Lake, UT 841ia*- Hollister. CA W= Vernon, CA SMSB w (000) 275-1121 (WI) 93s..1665 (831) 6'30-1093 (323") 3�-860D VE 8,lA�3ta TSIJCJST83 TWOST 26 owC TREA [F ice tlfy that i have been authorized by the applicable state agency to accept untreated medical wastes and that I have T- received the above indicated wastes I accordance with the requirement outlined in that authorization. ArbLm " 3 Z013 pe Signature Date . V1.