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i • Stericycle- ASE OF EMERGENCY CONTACT: CHEMTREC 1 -ND 1 STANDARD MANIFEST 001-10-06•STD <br />®• Rohct60 People. lei RW <br />1 renn.:.e...I- p,iA.dd� on.d Tnlft-l—d IU"� "r <br />LW <br />ATTN: Caria Vallem/Project <br />BIO/ST JOSS IMMED CAIM/OCCHLTH <br />1801 E. MARCH DANE BLDG 470D/480D <br />STOCKTON, CA 95210 <br />(209) !162-6395 <br />3117/2010 <br />CUSTOMER NUMBER 6062804-003, GENERATOR'sREowmAnona <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINERTYPE • <br />2C. NO. OF <br />2D. VOLUME <br />REGULATED MEDICAL WASTE, n.o.s..6.2, <br />CONTAINERS <br />UN 3291, PG II <br />BS02/RS02 - 2 Gal Sharps Reusable (0.3 cu ft) <br />Cul <br />REGULATED MEDICAL WASTE. n,o.s.,6.2, <br />UN 3291, PG 11D=- em <br />8503/RS03 - 3 Gal Sharps Reusable (0.4 cu Lt) <br />Cu I <br />1D= <br />Q <br />REGULATED MEDICAL WASE. n.o.s.,6.2, <br />UN 3291, PG II DOT -SP <br />BSOO/RS08 - 6 Gal SharpS Reusable (1'.1 Cu Pt) <br />Cu <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />BS17/RS17 - 17 Gal Sharps Reusable (2.3 cu ft) <br />UN 3291, PG II <br />Cu I <br />W <br />W <br />REGULATED MEDICAL S , n.o.s.,6.2, <br />UN 3291, PG II <br />TBO2 - 150 Gal Reusable (17.4 cu tt) <br />Gu I <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />UN 3291, PG 11 <br />Cul <br />REULAUN 3291.PGMEDICAL WASTE, n.o.s.,6.2, <br />n' ® 4.3 c." <br />r7 <br />4-3 Cu i <br />REGULATED MEDICAL WASTE, mo.s.,62. <br />UN 3291, PG 11 <br />XR65 - libeeled Rack 159.6 cu ft <br />Cu I <br />�►X 4a 3 <br />2- <br />8 6 <br />_ <br />. Cu I <br />1gPd %&at&Aa -1 hereby declare that the c bntents of this consignment are fully and accurately TOTALS i' <br />12-41 Cu I <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/ptacarded, and <br />are i1n all respects in proper condition for transport aecordi to applicable international and national governmental ons." <br />�re <br />`i�v �tr1l�_ <br />310 4,® <br />IPrinted/TypedName ! Signature <br />Date <br />�. <br />0 <br />4. TRANSPORTER 1 ADDRESS: <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> as cribedabove <br />Print/Type Name V. Signa ure <br />Date <br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Phone #: <br />`yWet. <br />Applicable Permit Numbers: <br />� W <br />mi <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Date <br />Print/Typs Name Signature <br />6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: <br />Phone #: <br />w <br />Applicable Permit Numbers: <br />U,a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />- <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />_ - <br />- <br />8A. Designated Facility: 8B. Alternate Facility: 8C. Alternate Facility: <br />BD. Alternate Facility: <br />S'TERICYCLE INC STERICYCLE INC STERICYCLE INC <br />STERICYCLE INC <br />a <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />TREATMENT FACILITY: I certify that I have been autho ' ed by the applicable state agency to accept untreated medical wastes and that I have <br />r <br />received the above indicate requirement outlined in that authorization. <br />0 <br />Print/Type Name _ Signature <br />Date - - - - - — - - -- <br />MAR 31 2010 <br />LW <br />