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• MEDICAL WASTE TRACKING FORM NUMBER <br />® <br />• �®® Steaticycle' 0 CASE OF EMERGENCYCONTACT, CHEMTREC 14tDe.424� STANQARD MANIFEST 001•ta.ae-1040 <br />•"°"�'°"""`""°+°'' --Route t3: 318 - 9 CUSTOMER NO. 21132 RDFR0087VT <br />1. Generator's Name, Address and Telephone Number <br />Am: Pedro Gonzalez <br />Stih1TER TRACY HOSPITAL <br />1420 N. TRACY BLVD. <br />TRACY, CA 95376 <br />9070156-002 <br />�uAisiaia�AmA�tir <br />(209) 832-6032 <br />8/2/2013 <br />2A. DESCRIPTION OF WASTE 120. CONTAINER TYPE 2C. NO. OF 121L VOLUME <br />UNMI Repined Medical Waste, n o.s.. <br />I CONTAINERS TB57 - 90 Gal Tub ( ' a) (12 Cu ft) <br />6.2. PGIi <br />C0 Ft <br />UN32Ml, Replated Medial Waste. n o.s.. TB4 9 - 37 Gal Tub ( al (4.9 Cts tt) Cu Ft <br />62. PGII <br />qq3aj., RoAted Medial Waste.nos.,I T1314 - 44 Gal Tub( O) (5.9 Cu tt1 <br />Medical waste. n.os .I TSA 1 - <br />UfUat, KegUMM Medical Waste, n.o s., T015 - 20 Gal Tub (Path) (2.7 cu tib) <br />8.2, PGIt Cu Ft. <br />UN329t, <br />Regulated Medial waste, n.a s.. TY15 - 20 Gal Tub (Ch o) (2.7 cu tt) <br />R 7 PP.11 _ _. <br />6.2, Poll CuFt. <br />UN3291. Regulated Medial Waste. n.o.s., <br />6.2, PGII Cu Ft. <br />Pharmaceutical titan <br />CUFL <br />3. Generators CerUNOallon: I hereby declare that tete contents of this consignment are fully and accurately TOTALS 0, CuI Al <br />Ft. <br />described above by the proper shipping name, and are classifted,packaged, marked and labeltedfplacerded, erld <br />are In all In propercondi% for transport Ing to inter and national ga+remmenial regulations' <br />Y, ,.� •' M _ ._ ✓ . ,J71 _l IS <br />4. TRANSPORTER i ADDRESS:p# ` t� 7 j b r a- i ►61 <br />Stericycle, Inc. is is a Through Shipment <br />4135 West Swift Ave. HaApplcable uler Ry Permit NlenbgrsN00 <br />a F O, Ca 93722 <br />a TRANSPORTER ICATI : Receipt of meds l waste as des«i <br />Pnnt/rype Name stgnawre pats <br />S. INTERMEDIATE HAIIIDLEA 2 / TAANSPORTER 2 ADDRESS: Phone #: <br />� E AppBCable Permit Numbers:INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as deserted above. <br />Prfntrlype Name solahme Date <br />�, S. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone #: <br />ic <br />111C Applicable Permit Numbers: <br />g INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Pdntltype Name Signatt" Date <br />1 IVA.73.':H:i4WJ LWAI,i0�ICiI� <br />&L Desigeated Fadi ty: <br />Sterlcyde Inc -Autodave <br />4135 W. SWFT AVE <br />FRESNO,CA 93722 <br />(559) 275 - 1121 <br />TS/OST22 <br />YI nsferred Contaluen, eu ft to : Noilth SakLake, <br />Off. AlternnaatteeeFacility. <br />Slad <br />94 NNORTA ;� rte an <br />VYEST <br />NORTH SALT LAKE CITY, <br />(841)936 - 1555 <br />3A 448-J1,36 <br />ttC. Af enuft Favi ty: <br />Sftrkyde Inc -Autocim <br />1345 Drtwe Sts C <br />San Leandro, CA 84577 <br />(SID)SO-2177 <br />T53UMACISTZ <br />So. Alternate Feelilty: <br />einc <br />2775 26TH STWET <br />VERNON, CA 94023 <br />1323) 3162 - 3Q44 <br />TSIOST 26 <br />TENT FACILITY: I certify that i have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />the above indicated wastes in accordance with the requirement outlined in that authorization. <br />Name Signsome Date <br />ZA•►��l1 ORIGINAL <br />