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see T MEDICAL WASTE TRACKING FORM NUMBER <br />the 0 •.Stericyde' kute <br />ASE OF EMERGENCYCONTACT.- CHEMTREC 14 00.42 STANDARD MANIFEST 00m048 -SM <br />• ""�°•"e'"• "ft #: 318 - 13 CUSTOMER NO NDFROOBAVL <br />1al10=1 ORIGINAL <br />1. Generator's Name, Address and Telephone Number <br />ATTN: Pedro Gonzalez <br />Stfl°= TRACY ROSPITAL <br />1420 1. TRACY BLVD. <br />TRACY, CA 95376 <br />(209) 832-6032 8/23/2011 <br />CuBsor m"UNaetll 6070156-002 G ,,TWIS <br />2A. DESCRIPTION OF WASTE <br />2e. CONTAINER TYPE <br />2C. NO. OF 2D. VOLUME <br />UN329t, Regulated Make] Waste. n.0.s.. <br />T857 — 90 Gal Tub ( ' o) (12 Cu ft) <br />CONTAINERS <br />6.2. PGII <br />Cu Ft <br />WWI Regulated MMkat waste. nos., <br />T849 - 37 Gal Tub (Bio) (4-9 Cu ft) <br />6.2, PGII <br />Cu Ft. <br />W <br />�i Regulated Medical Waste, nos., <br />TB14 — 44 Gal Tub (Bio) (5.9 Cu ft) <br />6 <br />Cu Ft <br />' <br />UN329I, Regulated Medical Waste, mos., <br />TWAL — AV <br />�I <br />82, P611 <br />Cu Ft. <br />W <br />UN3291, Regulated Medk21 Waste, n.o.s., <br />TSIS - 20 Gal Sub (Path) (2. Cu t <br />W <br />6.2, PGII <br />Cu Ft. <br />6.213 1GII , RegalatedMedkal Waste, n.os.. <br />8.2,.P <br />TY15 — 20 ural Tub (Chemo) (2.7 cu ft) <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n,o.s., <br />62, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />Pharmaceutical Was <br />CIA FL <br />3. Generator'® Certification: 9 hereby denote that the contents at this consounent are kft and aa>auataly TOTALS ® 1hV % <br />Cu FL <br />described above by the proper shipping name. and are d uslfied, poftgW, rdexl, and <br />are in all respecteriq proper tm I! pn lot transport according to applicable IntembonW and national govern I regulations' <br />X.Pd,=&NL "-" <br />"' ture <br />4. TRANSPORTER 1 ADDRESS: tie M: <br />Stericycle, Inc. This is a Through Shipment <br />4135 iiTwt Swift Ave. HaulerRt;n400 <br />CR <br />Freano,Ca 93722 <br />a 4 <br />TRANSPORTER CA"I%. Receipt of medical waste as . <br />111 <br />Ptinb' ype Name Signature Date <br />.. <br />6 INTERMEDIATE HANDLER 2!TRANSPORTER 2 ADDRESS: Phot t: <br />n � <br />APP9cable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of meftal waste as described above. <br />Print type Nam Signature Data <br />vs <br />S. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone & <br />Applicable Pam% Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Rawpi ot rrmlical waste as descrilied atm. <br />s <br />PdnttrM Name Signature Date <br />7. DISCREPANCY INDICATION <br />Thmfelred Canialmrs, ou ft to: North Sas Lake, UT <br />® QA. Designated FadiHy: 89. Atternsts Fadi ty W Allannum Facility: SD. Afterniale FSCWd r. <br />SteftWe inc-Autodtsva Itdc-AUWdm <br />Sbatcyde Inc Autodsve Stericycle Ino- lndrmdOn <br />1345 Culla Drive Sts C 2775 26M STREET <br />Qit <br />4135 W. SWIFT AVE SON 1100 <br />u <br />FRESNIO.CA 93722 NORTH SALT LAKE CITY, UT Sart Leandro, CA 94577 VERNON. CA 90023 <br />f- <br />(552) 275 -1121 (801)936- 1555 (510)50- 2177 (323') 362 - 3000 <br />all <br />TSIOST22 3A-448,14.36 TS311iS110ST23 -26 <br />11TMENT <br />TREPf�A\4.��s <br />FACILITY: I certify that I have been authorized by theapplicable state agency to accept untreated medical wastes and that 1 have <br />1. -received <br />the above indicated wastes in accordance with the requirement outlined In that authorization. <br />Prt2 3 2011 <br />NamtlUG Signature Oate <br />1al10=1 ORIGINAL <br />