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0 MEDICAL WASTE TRACIONG FORM NUMBER <br />•00 Stevicyde, 0 <br />CASE OF EMERGENCYCONTACT.CHEUMEC1-800+t2a+s STANDAW MAMFESTaot•10<64TD <br />• 'Route #: 318 - 10 CUSTOMER NO. 211 KOFROOSORO <br />I. Generator's Name, Address and Telephone Number n# <br />ATTN: Pedro Gonzalez <br />S WIMM TRACY EMPITAL f <br />1420 11. TRACY BLVD. <br />TRACY, CA 95376 <br />(209) 832-5032 6/14/2013 <br />CuMOMNt Usan 6070156-002 GetaliurroirsREGIBMTKA1 <br />2A. DESCRIPTION OF WASTE <br />20. CONTAINER TYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3291. Regulated Medical Waste. nos., <br />62. PGII <br />TB57 — 90 Gal Tub (Bio) (12 cu ft) <br />CODITAINERS <br />Cy Ft. <br />6 N3291, Regulated Regulated Medical bgraste, n as , <br />TB49 — 37 Gal Tub (Bio) (4.9 Cu tt) <br />Cu Ft. <br />UN3291. PGIRegulatedafediealMtdste'aos' <br />TB14 - 44 Gal Tub (Dia) (S. 9 eu tt) <br />p <br />Cu Ft <br />4 <br />UN3291. Regulated Medical Waste. n.os.. <br />s.2, PGtI <br />TB21 — 20 Gal Tub (Bio) ( .7 au ft) <br />W <br />Cu Ft. <br />W <br />UN3291, Regulated Medical Waste, mos., <br />6.2, PGti <br />T815 - 20 Gal Tub (Path) (2.7 cu tt) <br />tZ <br />Cu R. <br />is <br />UN3291, Regulated Medical Waste, n.os., <br />6.2. PSI! <br />TY15 — 20 Gal Tub (Ch o) (2.7 Cu ft) <br />Cu FL <br />UN3291, Regulated Medical Waste, n.os., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, a.os., <br />6.2, PGII <br />Cu Ft <br />_aarmaccuiiCal wastel <br />QU Ft. <br />3. Generators Certification: `I hereby declare that the contents of this consignment ' are frilly and accurately TOTAAL�0,t .7 Cu FL <br />described above by the proper shipping name, and are classliked, pacluagecl.marked and laballecV0acarded, and <br />In all respects In proper condition for transport a000rding to applicable i 6a and rational governmental regulations' <br />Aare <br />I I Printed/Typed Nara Signature ` Date ~� <br />4. TRANSPORTER 1 ADDRESS: Phone#: (559) 275-1121 <br />Stericycle, Inc. Ef This in a Through Shipment Applicabig pond,menbers: <br />a <br />4135 tilt Swift Ave. Hauler Reg# 3400 <br />g a <br />Fre ano, Ca 93722 <br />CL <br />TRANSPO :Receipt of medial waste as d <br />~ <br />Print/Type Nanta d/ Signature DaM,�i�T 1 <br />S. INTERMEDIATE HANDLER / TRANSPORTER 2 ADDRESS:Phone <br />a <br />Applicable Pam* Numbers. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdnVTWm Name Signature Date <br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone M: <br />aApplicable <br />Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: FIGNIpt of medial waste as described above. <br />PrinVType Name Signature Date <br />7. DISCREPANCY INDICATION <br />tSa$ <br />TnmS d Cb rdMiltel"S, OU 2 to : Nbalth Lake, UT <br />y <br />Q BA. Designated Fatality: 08. Anarnda F 8C. Anent Facility: ID. Alternate Fadaty: <br />v <br />Inc-Autodave �Ii�'tMMIN Slsl� a InC-Autodtgt/e IncAuGadave <br />26717 STREET <br />q <br />4135 W. SOAFT AVE 90 NORTH 1100 WEST 1345 Doo=e OrMe Ste C 2776 E <br />FRESNO,CA 33722 N , U Sen Lsandro. CA 84577 VERNON, CA 30023 <br />362 <br />W <br />(558) 27S - 112 f (801) (510) 562- 2177 13233 -M <br />TS31MOST25 TS►OST 26 <br />2 3A-448,JA-35' <br />CTREATMENT <br />FACILITY: I certify that I have been a rized by the appli le state agency to accept untreated medical wastes and that I have <br />I- <br />received the above indicated wastes in accordance th the requirement outlined in that authorization. <br />PrinuType Name Signature Data <br />