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11/12/2010 14:19 209239 BUSINESS OFFIGRiL PAGE 23 <br /> — -- -�w— MEDICAL WASTE TRACKING FORM NUMBER <br /> IN case t EMEFIGENCv coNTACT.CMWwMl9C,-tf00�424- )W 8Th IDAAD MANIFEST 001•ttl�fi SYo <br /> ®0 0 5 `wNe.!,ew .r«: 301 - 26 DFRO09GWD <br /> Routs >�. <br /> I.Geneww's Name.Ad andTelepharie Number I �' <br /> ATTWa Cathy/Maxine <br /> MANTECA CARE & <br /> 410 EASTWOOD AVE <br /> 4QrmcA, rA 95336- 3167 <br /> (209) 239-122' 6/3l201( <br /> CWTOMOtNUMBER 6059477-002 GEMEFUCTU •gfia"Al"NA <br /> 2A.OESCRA'TION Of WASTE 2®• CONTAMERTfPE 2C.NO.Of 20. VOLUME <br /> COMTAIkER$ <br /> 0329),R49t0atrd Medical W".11,0-S- 707 - 90 Gal Tub (Bio) (12 cu 'Et) Cu Ft. <br /> 6.2.PG11 <br /> UN3291,ftculded Maul WVJW U.O.L. T949 - 31 G11 TUb (Bio) (4.0 Cu tt) Ca Ff. <br /> 6,1„0(111 QQ <br /> W UN3291,R6991310d M�loat Wawa,11.0 TOLL - 44 Gal Tutb(Bio) (5.9 Cu tt) I •a/ Gu F1. <br /> ® 6.2.PGII <br /> C 5143291.R Medical Whi ne.no.e., T821 - 20 Gal 'Eub(143 0) (?..7 cu Et) <br /> Q 6.2.PG11 Cu Ft <br /> .- <br /> 1z <br /> IJN3291,Re [aW Medal Wasle.110.5., T815 - 20 Gal Tub (path) (2.7 Cu tt) <br /> Z 6.2,PGh Cu FI, <br /> -U-W1.ii6gWated Medkal waste,11.a.s., <br /> I <br /> U.P611 ?Y15 - 20 43e1 Tub (Chemo) (2.7 eta tt) Gu Ft <br /> 11143291,RWIMed Medical W-01e,11.os., Cu cL <br /> 6,2.Pun <br /> UNMI,ReVgWaled AAed1@31 Waste.O.o.s., Cu A. <br /> i 6.2.PGII <br /> phamaceur4ca1 waste gg Corn <br /> 3.ger ator'9 Cert111e llon:M hereby docklm eral the contw"of"'m consign"M aro fully and accurately TOTALS 1 5 -� Gu Ft. <br /> 4C ftad above by the proper VdppbV llama,and see clesalffed,pAP.rr�)Aad,marked�lobrtikd/pt a <br /> aro in ad renpectt In proper oor4tion for tran,apon So appHoWe infernatlorntl onC rAgulalio s: <br /> �-- is 3 <br /> 1%..11 12012 Typed Nam* s noturo Data <br /> 4,TRANSPORTER t AMME S. Phonr�M: (559) 275 - 0 <br /> Stericycle, Inc. Ar,pnca,t>aoPclrmuNumbers: <br /> a 4135 Rest 5"-I Ave. <br /> -M is is r, ShiraaF9nC <br /> gp�r rre�ano,Ca 93722 <br /> R Q <br /> TRANSPORTER <br /> RAN C) L.ESa RCATION:R4MNp)I3F m@d C�t�•. 1 AA d89C1I SL10W1• <br /> Prirtt(type Net+x Skmature Dam <br /> S.IN7FRMEDIATF HANDLER 2;TRANSPORTER 2 ADDR@5S. PI'O� <br /> ApplireNn Parmlt Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Rormftt of madicaf wtaato os de..-Oft atmvrs. <br /> l PtinUType Nance Signulurp Date <br /> S.tN1'ERMEDIATE HANDLER 3/TRANSPORTS 3ADDRESS, Phan®6: <br /> Applicable Permit Numbora: <br /> X11' IKMRMEDIATE HANDLER ITRANSPORTER CERTIFICATION:Receipt.of ft-oul wast6 as dc+ecrkW show+. <br /> x <br /> a <br /> PrIn0yo Mantle Signature Data <br /> 7.D13 REPANt~Y INDICATION <br /> Q TTS (aonla6 ds A to: NoRII SaA L I)T <br /> A M.D"Mpnlyd 04CMtr. 09.AR+n.+nM foeUlry ' ac.AeMn+sto+vnelWty _ — AD. Fweell1•: <br /> { S4eriCyds)ne-ALdOtIBtrA SWdeicle Ina Ind ngrs9oet Stedcyda Ir1e-A1dpdRve SWrLyde Pr1G-AfftC <br /> ( Kt 4439 W.SWFT AVE go Nofm 11x0 VYE'STT 1345 D00106 C IW4 M C 2775 E 2611`1 <br /> � Na,CA 93722 WORTH 1,AKE CITY.UT sen CA 94577 VERNON.CA SOM3 <br /> FRES(559)276-0994 (W I)93s-1566 <br /> (51 tp S82- 17B I 13241362 a 210W <br /> 1331,TSMST26 TSM" CIassV Inchandon Pemt#91 02 M.P-116 <br /> 7REATTAENT FACILITY;i cEN tt(y that I have been€tithorixed by the Apolica stale FD etxept untrnatrtd rnedlcel vrRSdtsG and lt1eR I ha+re. <br /> Imo- receNed the above 1 teS in acc mane with the requirem ned in �tlorizelicn. <br /> yJUN 0. 29t <br /> Signatu <br /> Qrlrv/FY1M Marne m .4 F.v -;!�� 1'�r�f'A:s^ _ Owe <br /> t1U1355 � <br /> ORIGINAL <br />