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11/12/2010 14:19 209239 _- BUSINESS OFFIC- PAGE 19 <br /> MEDICAL WASTE TRACK G FORM Nt MsER') <br /> •®; 5 1N CASE 00 EMINIOENCY C i 6TAMMM MOPOFM an-100546 <br /> Route f; 301 - 21 MOFROORRM <br /> 1. ' ator's Name,Adders and Te"hona NUMbOr <br /> ATTM; Cathy/Maxine <br /> MAWff,CA CARE & RFIMB <br /> 410 EASTW= AVE <br /> M T'I'ECA,, CA 95336- 3167 <br /> (209) 239-1222 12/10/2009 <br /> Cu3mmmlVcamm 6059477-002 C16NERAi06Ya AFOWPATION0 <br /> 2A.DMCmPTl M OF WASTE 29. CONTAINEATYPE 2C. NO.OF 211 yOLUMt <br /> REGULATED MEDICAL WASOF.n.o.L.V.., T�7 - 990 Gag •Cash (ftioO (z2 cu ti=t) - COMTAINERS <br /> UN 3291,PG 11 Cu FL <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2. T90 - 37 e^,dl xuh ,Ilio.) (4.9 cu tt) <br /> UN 3291,PG It _ �gL <br /> ac Il£GULATED MEDICAL WASTE,n.a.s.,6.P„ T814 - 44 G.41 Tub(Dio (5.9 cu 2t) ~- <br /> ® LIN 3291,PG It Z' t®a y FL <br /> 4 REGULATED MFOICAL WASTE,n.c.s.,6.2, Tt32l - 20 r3s1 Tub(Ria) (2.7 Cu ft) <br /> ¢ <br /> ON 3291.PG Ir <br /> W IREGULATWMEDICAL WASTE,mn.4-13.2. TB15 - 20 941 Tub (Path) 42.7 Cu ft) <br /> WON 3291,Pl:a ,a� eyaa Fl. <br /> REGULATEOMEDICALWA$IE',n.p.R„G,2. TYAS _ 20 ®a1 Tub (Chemo) (2,7 cu ft) <br /> UN 3291,P6 rl m GI FSS. <br /> R""LATED MEDICAL WASTE,n.a.s.,6.2, <br /> UN 37 PG I I Cu F,, <br /> REGULATED Mr-DICAL WASTE,n.o.s.,G.2. <br /> i UN 3291,P6 It Cu Ft. <br /> Pharmaceutical Waite <br /> u FL <br /> 3.Got tore CertHloeatlont 9 herby dec*#my the oontelds or this consignment nm hilly Anel aaoiimloly MTALS ® Z. , ou it <br /> dt�CHpod above by the proper gypping name,aid are classified,packaged.martod and febp%ed/pl d.end <br /> pra In oil rospoets In proper condition for trensOort accOfifing to aP!kwbin Int no ml and national go%1W r latlo a- <br /> 1 AR NINA` 4N�u <br /> 1 ltfnea blame St ntatum Rahn l Ro 4 <br /> IT A.TRAN$PORTI&AIADDRESS` Phom#-. (559) 275 - 0994 <br /> Stelricycle, Xnc. Applicalft PArmhMamtim! <br /> 4135 West Swift Ave- <br /> ` o Thies a The gh shl.pmont <br /> f CL Fresno'ca 93722 <br /> I <br /> TRANSPORTER CERTIFICATION:Racsipt of medical wa9te as described above. <br /> IE / e� 1 <br /> pArnllypa wr” �' r' �nAtv(* IJnm ® / O i <br /> 5.INTF.RMIEATF NMOLER 2/TRANSPORTER 2 AMRIESSi Plane N; <br /> M AD Permit Numbem: <br /> INTERMEDIATE HANDLER ITRANSPORTER CERTIACATION:Recelpi of me".este as described abm. <br /> PritWTypa Name pato 11 <br /> ;;w 6.INTERMEDIATtr NANOLER 3/TRANSPORTER 3 AMRESS: Phalle M: <br /> 3 <br /> 65 pptt .; APeMA Numbers: <br /> Lo 1INTERMEDIATE HANDLER f TRANSPORTER CERTIFICATION:l teeerpt of modloal wma mo dotcfted oboe+:. <br /> H <br /> pm+/"f c"hwe onto <br /> I 7,DISCREPANCY INDICATION <br /> Tmthmid cimalmrs, an ft IQ , Namb Salt Lake,UT <br /> aA.OftAp~FWWy: ate Attmmwto FMINW ®C.Aftmoto R'd iwi. q®.Afr mwM FrmeN(ty; <br /> ICYCUE INC STERICYCLL INC STERICYCLE INC STEPICYCLE INC <br /> O 4135 W.SW PT AVE SO NORTH 111W WVEST 9053 NORMS AVE, 2775 E 2M STREET <br /> FRE9N0,CA 93122 NORTHSALT LAKE CrrY.LIT SUN VALLEY.CA 91352 VERNON,CA 2=3 <br /> (569)275-OM (8101)936- 1555 (8 is)04-5937 (323)362-3MO <br /> w <br /> M1'19=725 1311OM2 COY Indneraftn® 9 PLG.14-116 <br /> W TREATMENT FACILI'T'1:1 •rti� fret 1 dove been authorized by the appilcabto stato ag®nc accept untre3Wead medical WaVAe and that 1 have <br /> r� li rA ARWid Ihp Abo"-' - gin Ace ordaneei with the rge�Iure?mAatt in th zRtion. <br /> t'nnLType Narng 7CQr' WIC ;,ignaturoov Date DEC Z®o] <br />