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— . - - - <br />- MEDICAL WASTE TRACKING FORM NUMBER <br />:: • Sttericyde' CASE OF EMERGENCY ACT: CHEMTREC 1 2 MAraFt:si' oot•io-0e^sru <br />•• <br />•"""°«`°•°" Route 0: 318 - 7 CUSTOMER Na 21 MDFROOBBUM <br />1. Generator's Name, Address and Telephone Number <br />Pedro Gonzalez <br />���!(m�����ATTN: <br />u11111111111 <br />SUTTER TRACY HOSPITAL <br />1420 E. TRACY BLVD. <br />TRACY, CA 95376 <br />(209' 832-6032 8/30/2013 <br />CUSMMNUUM 6070156-002 GEDUMTOWSREG tM=Me qq <br />• <br />2A. DESCRIPTION OF WASTE <br />20• S14pH 20allempharamaC AINERTYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3291, Regulated Medical Waste, mos., <br />CONTAINERS <br />62, Poll <br />S22PH %GallaaftwunsCankaim <br />a, Ft <br />UN3291. Regulated Madloal waste, a os., <br />62, PGII <br />S'3M 1110allaoPharmsComuiim <br />Cu FL <br />Q <br />UN3291, Regulated Medical Waste, e.os.. <br />62, PGII <br />S32pHA+ 8 gatlmepttuamaG +ride <br />` ® <br />Cu FL <br />Q <br />UN3291. Regulated Medical Waste, aos.. <br />Tasasparter <br />6.2, PGIICy <br />FL <br />Ill <br />UN3291, Regulated MedkW Waste, n&L. <br />6.2. PGIIQjljpn2"CZWgMCu <br />FL <br />LLZJ <br />UN3291 Regulated Medical Waste, mos., <br />i <br />6.2. PGII <br />e►� u r .n. ae......r_,...,.:..- <br />r , C, <br />3. Generator's Certification: "1 hereby declare that the c orderds of this consignment are fully and accurately I TOTALS 01 `, I6. `y <br />desorbo above by the proper shipping ram, and are classfNed, norked and ed/plecarded, and <br />are in all in proper =%didoon for c aoordirg to applicable Int ti onal and nationst governmental regulatby,;.. � <br />Priruedrryped Name Le—W Signature <br />eg 4. TRANSPORTER t ADDRESS: . Phone ft: - <br />w Stericycle, Inc. if This is a Through ShipmentAppkaft Permit Numbers: <br />4135 (fest Swift Ave. Hauler Reg# 3400 <br />Fresno, Ca 93722 <br />CE Z TRANSPORTER FICAn (W* of rneftsi waste as d <br />Print/Type NaraSlgnaarre bate te ` <br />S. INTERMEDIATE HAND R 2 / TAANSPORTER 2 ADDRESS: Phone M <br />N 1 Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: t of mod" waste as deseribed above. <br />Print(Tjpe Name Signature Date <br />r, W Y. In 1 cnMCulf" C rvurua.crn a I 1 nwva,-vn 1 Cn 3 owuncoo: alone is <br />19; Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medk:W waste as desioribed above. <br />PrinVTjrpe Name Signature haste <br />17. ;rNCY INDICATION <br />it Transferr � containers, cu h to : North Salt Lake, UT <br />eA uao 8a. At<emMe ReIntn10C. Atiarrwee Fad1w. eD. AMnnet• Fury: <br />jja itttrctnva Stert>Lyde Ino- In on CHAMBER INCINERATOR Sterkyde Inc-AuDodave <br />to Therese Ave. .: 35 "SriWe <br />7501 Stabil Hwy 65 28161 KEITH DR. <br />tea. FtSSttO. CA Q. 7n Anatwr!tt, TX 77514 LAKE FOREST. IL 5 <br />(659) 8345860 (559) 27(409) 267-8206 (8D0) 643.024D <br />TS/OST'22 MWfSIOST PERMIT 8 MS�ti2239A <br />t^ <br />TREATMENT FACILITY: I certify that I have been authorized by the applicabte state agency to accept untreated medical wastes and that i have <br />I- received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />a^.� r•:...� ��Ttz <br />PrinirrypeN `arra '"J' : O Signature Date <br />AUG 30 Cdfl <br />oes5s <br />mfAewetar�i?S3t! a(�ituezost ORIGINAL_--- — - <br />