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®®. -- _ •- __ .....__ _ MEDICAL. WASTE TRACKING FORM NUMBER <br />000 Stericycle' 1N CASE OF EMERGENCY CONTACT: CHEMTREC 1.800.424-9300 srANoaRo MAtBF>:ST 001 -IM -SM <br />• trou tft"..amoW Route 94 100 — 29t CUSTOMER NO. 21132 MDFROOEi' 6CM <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />CALIFQRmA MEDICAL FAciu F <br />1617 1 CALIFORNIA ST <br />STOCKTON, CA 95204- 6117 <br />(209) 948-6435 9/17/2013 <br />L41r1 urnNLM APA 6039552-002 GmiERATowsREersniAnontif <br />2A. DESCRIPTION OFWASTE 2131. CONTAINERTYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3291i Regulated Medicalwaste, n.o.s„ TISOS — 40 tial Tub (Bio) (5.3 Cts fit) <br />CONTAINERS <br />Cu Ft <br />6U2, PGII Regulated Medical Waste, n.o s., T849 — 3'. Gal Tub (Bio) (4.4 cu tt) <br />Cu Ft <br />RegulatedMedtcalWaste,n.as., TH14 - 94 Gal Tub (Bio) (S.9 cu ft) <br />60"I' <br />8.2. PGIi <br />Cu Ft <br />UNN32 11Populated Medical Waste, n o s., TB21 - 20 Gast Tub (Bio) (2.1 cu �ft) <br />UFrill <br />Cu Ft <br />&23PSIi Regulated Medica! e, n.o s., TP25 - Ztl Gad Tub (Path) t 2.? ctt ttj <br />Cu Ft. <br />B 21 PP611 Regtdated Medical Waste, n.o.s., TY15 - 20 Gal Tub (Chemo) 42.7 ecu ft) <br />Cu Ff <br />UN3291 Regulated Medlcai Waste, n.o.s., M - Siosystems Cardboard Box (4.2 cu ft) <br />UN 2 1 Regulated Medical Waste, n.o.s., <br />Cu Ft <br />Phamnaceutical Mass <br />3. Generator's Certification: "1 hereby declare that the oontdnts of this consignment are fully and accurately <br />rte_..__...�__ L__ ___._ <br />TOTALS Ph - <br />CU Ft. <br />UCSD <br />are <br />4. TRA 4. 1 <br />�- a <br />TRANSPORTER <br />PdnVTWo �'�c%�i';�.��J://.1/,-<'/� ,,'�ri,'!!L!!/JIJ`/J.'!•.�x�/f .: [ it/,l�l <br />Name_ <br />[on for sport ac r g to applicable Internatsonal and naponaf governmental regWet`ona" <br />Q Phor®x: (b65-1121Steri le, 1nG. This is a Fment APptcsble Permit Numbers: <br />I <br />Q <br />4135 W. Swift: Ave <br />Fresna,CA 93722 Tiauler ltegft 3400 <br />MFICAVQN: Recalpt of medcal waste as described above. _ 1 1 <br />Data <br />8ENT <br />. ERMt_DIATE HANDLER 2 JTRA QRTF.R 2 ADDRESS: Phase k: <br />Applicable Permit Numbers:. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Prinlrrype Name Signature Date <br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER S ADDRESS: Phone g: <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdnVType Name Signature Date <br />7. DISCREPANCY lNDICATtON <br />Transferred cortiainers, dI ft to : North Salt lake, UT <br />Doslgnated Facility: <br />Stsrlcpcie, I= <br />4135 W, S►N RAVO <br />Fresno,CA 93722 <br />(559) 2'36-1121 <br />TS10ST22 <br />80. Altemato Facility: <br />Ste e. Inc. <br />so oto D&e <br />North $aft Lake, UT 0405- <br />(801) MS -1556 <br />&4rA8,1f436 <br />60. Allemate Facllily: <br />Stedcyde, Inc. <br />1651 Shelton Drive <br />I Hollister, CA 85023 <br />(831) 630.10913 <br />TWOST 83 <br />80. Altemate FaciBty: <br />5terlgcler, Inc. <br />2775 E. 26th St, <br />Vernon, CA 30068 <br />(323) 362-300a <br />TWOST 26 <br />Hify thatI have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />was I accordance with the requirement outlined to that authorization. <br />ORIGINAL <br />Date <br />