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11/12/2010 14:19 209239dQLq BUSINESS OFFIC PAGE 15
<br /> 6% tort/ ", ,' +art et ai;R�ra�r_ruecrw NUMOM e
<br /> 0 5tericycle IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800-234 1 +nns�C1D
<br /> ft"C1"ftW&R1ftdpRbt: Route s t 301 - 24
<br /> SERu1rl RE&FIPT
<br /> 1.Gen'erator's Name,Address and Telephone Number AC, e, �
<br /> ATTR. Cc7>~I]jP't1�r7xine Nenl,Care 8 Ve77-002
<br /> ERVICt OA>E; ab
<br /> MANTECA CAM a'' W11UFR 111; E;1 �J;34 AH
<br /> 410 EASTROOD AVE sr♦r1�1r�
<br /> MAMCA, CA 95336-- 3167
<br /> (209) ;239-x?22ro AL � afg.. 1
<br /> $.� CU FT
<br /> MAOOVA
<br /> euvroMEN Nummen 60 5 9 9'7 7-00 2_1m
<br /> Ga ffmxrotrs pnGIsATION� T914
<br /> 2A.DESCRIPTION OF WASTE 20. CONTAINERTYPE
<br /> REGULATED MEDICAL WASTE,n.o.s.,6,2, TB57 _ 90 qe), Tub (Vto) (12 ou 'EZ) (Cont Ty�)�� �
<br /> UN 3291,PG II i®14 44 Gel iub OR CF LF,
<br /> REGULATED MEDICAL WASTE.n.o.s.,6.2. T�t49 — 31 Gal Tub •(Dio) (4.9 m, t''C) (Bio} CT 1P�
<br /> UN 3291,PG II ' BRIM 5.9M Gu Ot
<br /> C REGULATED MEDICAL WASTE,mo.s.,6.2, TE14 - 44 raa7. Tule(Rio) (5.9 CU ft) OUCLp rT r; Y
<br /> UN 3291,PG 11 Tork
<br /> REGULATED MEDICAL WASTE,n.0.6„6.2, - Ua.L .o al cTWE
<br /> U 3291,PG 1 Aw
<br /> U REGULATED MEDICAL WAETE,M-0-8-6.2, T5 5 — 20 Gal Tub (Path) (2.7 au tt)
<br /> UN 3291,PG II T814 44 GalCT12.) 1REGULATED MEDICAL WASTE,n.o.s..6.2, TY S 20 Mal Tub (Chemo) (2.7 cu !t) bUN 3291,PG it
<br /> REGULATED MEDICAL WASTE,mo.s..6.2, "•;
<br /> UN 3291,PG II Cid`.
<br /> REGULATED MEDICAL WASTE,n,o.s.,6.2, Fp�r�y. V G ''
<br /> 9/06
<br /> UN 3291,PG II �I pt*, 6/1Y
<br /> PirsimsemItIcal Wavo CIISTOI R SERVICE;
<br /> T1•ank Y�r fur chajsl�1sprER!Yee .• .;,
<br /> 3.Generator's Cortlficatlam"I hereby declare that the contents of this consignment are fully and accurately Cu:
<br /> deacdbed above by the.proper shipping name,and are dasslfled;packaged,marked and labelled/plaimrd
<br /> are in all respects in proper conglflori for Aransport according to applicable international and national Bove I
<br /> 7
<br /> I
<br /> I
<br /> PdritadlTy, d•Name Z Signa re w
<br /> 9.TRANSWORTER ADDR SS: ;cycle, Inc. PMolie (' ,..
<br /> 4136 t Swift: Ave. \,��,,,...�� App►table Permit Numbers':
<br /> p 7I4tin in a 't rough Shipoent:
<br /> C6 .'F resno,Ca 93722
<br /> TRANSPORTER CERTIFICATION!Receipt of mefcal Waste aS described above. t
<br /> Prim=Meme �,':: ..� r• ;✓, "�_. ,' Signature J Data
<br /> s.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADORERS: I'hore'M',
<br /> AOIcablp PNmIt Numbers:.
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical Waste as described above,
<br /> Z :.
<br /> Print/lype Name Signature Date ^,
<br /> m
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPOFt1 SR 3 ADDRESS: Phone it: ()
<br /> e
<br /> Applicable-Permit Numbers:
<br /> Uja '
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Data
<br /> 7. 'SCREPANCY INDIOATION ro, to A to
<br /> aA.Designated FadNty: M Aitem67ft Foal"., ®8C.Altemob-I'Setltty: S%Aftrngtm Facility: a
<br /> �. 3TEMCY INC CYCI..E INC STE •INC CY SIC .
<br /> 4196 W.S W FT AVE t IM WESdT 1345 :2 778AS29M SIR.2
<br /> FASSN04A 931722 NORTH SALT LAANZ CITY,UT $A N LVANnf t0l,CA 24M V .20
<br /> (559)27'5.0994 (Sol)M- 1965 (6141) .,No
<br /> l
<br /> TV51.T3iC1=$
<br /> POMW 91-M
<br /> TREATMENT fACILITY: I certify that I have been auth&.zed by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the above indicated wastes in accordance with the requirement ouvinbd in that authorizatlon.
<br /> PrinUType Name Signature Date
<br />
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