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11/12/2010 14:19 2092394 BUSINESS OFFI PAGE 22
<br /> t�A _ � •• MGve`sec•nna.rc.•eeeesvnrrverrvnm-e.u,.,oGrm
<br /> ®®• Stericycle' IN CASE OF EMERGENCY CONTACT-CHEMTREC 1=840 STAiVDARD NIANIFEBT OOt.tO�oe•sTD
<br /> !®. ►rerr s.r .aTrwegmar: ltnttt �tU A. - 2EA f .... '�_.:ixo o--V•4-93f)t3
<br /> 1.Generator's Nam®,Address and Telephone NL
<br /> ATTN: 'Cat'hy/Maxzrte
<br /> MANTECA CARV & REHAB SERVICE RECEIPT
<br /> 410 1r;ASTtB x 17 AVE ;
<br /> 3161 1�'t F.Cik, CA 95336-- � T C X159477-002
<br /> FIA
<br /> F�Itteca Care 1i Rehab �
<br /> SERVICE DATE, 4!1!10 10:58:13 AN l^'1.222
<br /> DRIVER 10: RP1
<br /> Ouvromen-NUMBER 60594"77-002 SHIPPING 0OC1- 9 KO 6
<br /> 2A,CIESCORMON OF WASTE 263. TOTAL MAECTEQ. 3 20. NO,OF 20. VOLUME
<br /> REGULATED MEDICAL WASTE,n.o.s.,6,2, TOTAL VOLUUIE: 10.1(10 CU FT CONTAINERS
<br /> UN 3291,PG II +t? 6da� C
<br /> REGULATED MEDICAL WASTE,n.o.s.A.2, T"49 - 3.7 qa7 0OA019L RX18 0OA019H RXIB ODA019(TBA
<br /> UN 3291 PG II -••-- GU Ft
<br /> REGULATED MEDICAL WASTE,n.0,0.,6.2. T1914 -. 44 G,41 M11HARY(C4nt Type) OTY Cr � CU Ft
<br /> UN 3291 PG 11
<br /> C. REGULATED MEDICAL WASTE.n,o.s„6,2, T112 - 20 Gal 18(18 16 Gat (Pharm), 0 Tare B 2 4.800 Cu Ft
<br /> UN 3291,PG 11 TBA 44 Gal Tdt(Blo), CT 12.7 1 5,900
<br /> A.• REGULATED MEDICAL WASTE.n,o,S„A.2, Rey. _ ZC1 ea:k CU Ft
<br /> UN 3291,PG 11. QEL I UdtY MC 7m
<br /> iREGULATED MEDICAL WASTE,n.o.G.,6,2,
<br /> 3 UN 9291-..!G 11 a`.Yir - :t9 4aeJ TOTAL DELIUFA Lti'Ft
<br /> REGULATED.MEDICAL WASTE,n•o,s.,6.2,
<br /> ou Fit
<br /> UN 341,PQ B TIRE QTY
<br /> REGULATED MEDICAL WASTE,n.o.s.,6,2, Cu Ft
<br /> UN 341,PG II T814 44 Gal Tub(Bto), CT 123 Ib 1
<br /> Rh4rWC6Ut1Ca1 Waste
<br /> 3,Generatar'a Conification:"I hereby declare that the cont+ Ft
<br /> deigbri6®rt'ab6a by the proper shipping name,and are claaa ORIUER: PARKA, RENE V nd :
<br /> are in all respects In proper condition for transport according FREDUENCY: leekly nt81 reguia0 s”
<br /> NW PICKUP: 418110
<br /> CUSTKR SERVICE: Date
<br /> 4
<br /> Printed Name Thank you for rhoosirg Stericycle phoh@*
<br /> 4.TRANSPORTER 1 ADDRESS: _ �$.
<br /> W St;,eric, cls, Inc. Applicable PermhNumbers:
<br /> 4135 Rest: Swift Ave.
<br /> a Jr z�anto,t"a a37�2 to 5tii}1">u't .
<br /> TRANSPORTER CE CATION: Receipt of medioa
<br /> .4'. •.,t, T,, .. '
<br /> f r>- 4y._ �' 'Data• .:�•! , ° .� .
<br /> Pant/Typ®Name __._ ----._._
<br /> S.INTERMEDIATE HANDLER 2l TRANSPORTER 2 ADDRESS: -y ' Phone W
<br /> g+ �� Applicable,Parmlt Numbers:
<br /> u7 eZ
<br /> INTEAMED1ATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Typa Name Signature Date
<br /> ,,,INTERMEDIATE HANDLER 3 1 TRANSPORTER$ADDRESS: Phi '
<br /> Aopilceble Permit Numbers:
<br /> CEFMFICA71ON: Receipt of medical waste as desc lbBd Above.
<br /> s INTERMEDIATE HANDLER/TRANSPORTER ,
<br /> Print/Type Name Signature Date --
<br /> 7.DISCREPANCY INDICATION
<br /> d Z a ' ' cu a to : Nattth SA Lake,UT
<br /> s&oesionated FaeBhy: 80.Alternate Faculty: ❑8G.Anemeto PaeiNty: U W.Aroen+at.F�Ility
<br /> 1 "CYCLE INC MRICYCLC KC $T�hICYtA1=INC S CY LNG
<br /> 41%K SWIFT AVE 90 N 111]0 VVKST 9=NQRW8 AYE, 2776 E.
<br /> ( FRMN0,0A 8M2 14ORTHSAL"I"1.AfC1`•CtTy,UT WN VALLEY,CA 243152362 0CA SM
<br /> (�i8y275- (iB18) t am
<br /> TS31, � T S10 C V1 - P t- F-E.P-11
<br /> e TFC90MENT FACILrTY: I certify that I have beenauthorized by the applicable state agency to apt untreated medioal wastes and that I have
<br /> received the above indicated wastes in accordance with the requirement outlined In that authorization.
<br /> Printlrype Name Signature Date
<br />
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