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4.n -NT 11: 6019288-003 Pacific Medical SERVICE DATE: 12/2 7 AM DRIVER ID: RJF SNIPPING BOrCUMENT ✓t: HOM001Z TOTAL Ct1LECTFD: 2 TPr" VOLT: 8,600 CU Fi 00h.,,,,jq T814 OOAOOQT TB1S SUNNARY(Cont Type)VOL QTY CF T814 44 Gal Tub(810), CT 12.7 1 5.900 T815 20 Gal Tub(Path), CT 5.7 1 2. AR) DRIVER: Fragus, Randy James FREQUENCY: Weekly NEXT PICKUP: 12/28/10 CUSTOMER SERVICE: Thank you for choosing Stericycle CASE.OF EMSF CTNCY C NTACT: CHEMTREC 1-800-42 STANDARD MANIFEST 001 -10 -06 -STD Lti11tP_ r 3111 - ° Getst: att1F to 132 P+Ii7F' Rt43AB1Z d Telephone Number r Exs?ct.ti i,,,e Assist :569 LORI OR MARCO ONI iTS15 -- 20 Gal Tub (Pa1t[1) 42.7 CU it) I � I 1 Cu Fl TY15 - 20 Gal Tub (Ct'ieMO) (2.7 Cu it) 11N3291, Regulated Medical waste, 6.2, PGII Cu F1 phaLmaceutical Wastel I I Cu FI 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and a described above by the proper shipping name, and are classified, packaged, marked and labeiled/pl are in all respects in proper c¢n ition for transport according applicable international and national ■LNam® Printedrryped Name �- . ' ` Signature Y W 4.iRANSPORTER1Sieriicyce, Inc. rQ 4136 West Swift Ave. '2(Th is is ,a Thrr,)ugh Shipment <0 Fresrto, Ca 93722 rn--, ; M Q TRANSPORTER GSRTIFIC ION: Receipt of medical waste as described aoove.•' Print/Type Name Signature ie* A r✓` �' ` IV"' e Date t Phone #: k ,.3-'t 4 Applicable Permit Numbers: Date ! u FI (30011 726-9380 Phone #: 12/21/20117 —003 GENERATows REGISTRATION # Applicable Permit Numbers: °C$o: CONTAINERTYPE 2C. NO. OF 21D. VOLUME INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. CONTAINERS TB57 - 90 Gal Tub (BiQ) (12 CU 1;t) r� Cu Ft fiB49 - 37 Gal Ttab (Bi?,) (4,9 0A ft` w a ¢ S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: Applicable Permit Numbers: IE w Cu Ft 'TB14 -• 44 Gal. Tttb (Bio) (5,9 CU ft) / _ .� Cu Ft iTS15 -- 20 Gal Tub (Pa1t[1) 42.7 CU it) I � I 1 Cu Fl TY15 - 20 Gal Tub (Ct'ieMO) (2.7 Cu it) 11N3291, Regulated Medical waste, 6.2, PGII Cu F1 phaLmaceutical Wastel I I Cu FI 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and a described above by the proper shipping name, and are classified, packaged, marked and labeiled/pl are in all respects in proper c¢n ition for transport according applicable international and national ■LNam® Printedrryped Name �- . ' ` Signature Y W 4.iRANSPORTER1Sieriicyce, Inc. rQ 4136 West Swift Ave. '2(Th is is ,a Thrr,)ugh Shipment <0 Fresrto, Ca 93722 rn--, ; M Q TRANSPORTER GSRTIFIC ION: Receipt of medical waste as described aoove.•' Print/Type Name Signature ie* A r✓` �' ` IV"' e Date t Phone #: k ,.3-'t 4 Applicable Permit Numbers: Date ! u FI IEATMEN T FACILITY: I certify that 1 have been authorized by the applicable state agency to accept untreated medical wastes and that I have :eived the above indicated wastes in accordance with the requirement outlined in that authorization. PrinttType Name Signature Date 5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: j Phone #: NLU .. Applicable Permit Numbers: °C$o: g Zw= INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. r� Printrrype Name Signature Date w a ¢ S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: Applicable Permit Numbers: IE w 020 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. z ui z Printrlype Name Signature Date 7. DISCREPANCY INDICATION 1 f�tti 11 % em , �2 • 7 eu 111 to - NOM Sioil Lake, UT y. a 3 'Ej8D. 8A. Designated Facility: SterlGyGie Inc -Auto 86. Alternate Facility: de Inc- Indnerrabo't BC. Alternate Facility Stef9cyde Inc A a Alternate Facility: S ericycle IncA sure W. SWIFT AVE 10 NORTH 1100 VW -ST .1346 Dot4 e M C 2775 E 28TH MEET a4135 a FRESNO,CA 93722 NORTH SALT LAKE CITY, UT San LewWro. CA 914577 VERNON. CA W023 (559) 276- 0294 (801)936- Ism (6 t 0) 562- 1781 13231362 - 3000 z TS31,TS/03726 TSIOST22 C:i V In P S# 2 P-6, P-11 15 w IEATMEN T FACILITY: I certify that 1 have been authorized by the applicable state agency to accept untreated medical wastes and that I have :eived the above indicated wastes in accordance with the requirement outlined in that authorization. PrinttType Name Signature Date