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9/24/2018 16:48 Remote ID
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<br />Imprint ID
<br />ASE OF EMERGENCY CONTACT: CHEMTREC t
<br />Route #: 301 - 14
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN: Caroline Jackson
<br />WAGNER BEIGHTS NURSING
<br />9289 BRANSTE'iTE'R PL REHABILITATION CEYM
<br />STOCKTON, CA 95209— 1700
<br />_D 2/18
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001.10.06.STD
<br />MDFRO09UY6
<br />(209) 474-0569
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />PhaL:RaceutiCal Waste
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in proper condition for transport Be ing to applicable international and national gover ental regulations."
<br />i
<br />Prtntew typed Name r Signature
<br />LU4.TRANSPORTER 1 ter -i& Icle, Inc.
<br />41135 West Swift Ave. This is a hcou shipment
<br />a Fresno,Ca 93722
<br />cn
<br />1z TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Cr
<br />~ Print/Type Name ' Signature
<br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS_ Phone #:
<br />5 - - - Applicable Permit Numbers:
<br />Mi
<br />i INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION' Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />„, 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />i 5 w Applicable Permit Numbers:
<br />:c-,
<br />W
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />i
<br />Print/Type Name Signature Date
<br />7. )VREPANCY INDICATION
<br />Transferred containers, cu R to : North Salt Lake; UT
<br />}
<br />9/6/201(
<br />2C. NO. OF 2D. VOLUME
<br />CONTAINERS
<br />Q i
<br />i
<br />1 1 5-
<br />< n
<br />O Date g
<br />Applicable Permit Numbers:
<br />Date
<br />u
<br />8A. Designated Facility:
<br />Sterlcyde Inc -Autodave
<br />4135 W. SWFT AVE
<br />FRESNO,CA 33722
<br />16591 275 - 0994
<br />X31, TSIOST25
<br />TREATMENT FACILI : I
<br />received the ab i
<br />Print/Typo Nam I
<br />o
<br />00. Alternate Facility:
<br />St;ericyde Ina Incineration
<br />90 NORTH 1100 WEST
<br />NORTH SALT LAKE CITY, UT
<br />(gilt) 038 • t 566
<br />TWOST22
<br />that I have been authorized by the
<br />les in accordance with the reqqiw
<br />�F d "M Signature
<br />Irae ao 02-sel,,2010 ORIGINAL
<br />8C. Altemate Facility:
<br />Stericyde Inc-Autodave
<br />1345 Doolittle Drive Ste C
<br />San Lsandro, CA 94577
<br />(5/U) 682-1791
<br />Class V Indneratii n Perrrd# 9
<br />BD. Alternate Facility:
<br />Stericyde Inc-Autodave
<br />2775 E 26TH STREET
<br />VERNON. CA 90023
<br />(22511 Z22 - ZMQ
<br />P6. PA is
<br />to accept untreated medical wastes and that I have
<br />orization. SEP ® 7 2010
<br />Date
<br />CUSTOMER NUMBER 6020465-002
<br />GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />28.
<br />CONTAINER TYPE
<br />UN3291. Regulated Medical Waste, n.o.s.,
<br />T657 - 90
<br />Gal Tub
<br />(Elia) (12 cu ft)
<br />6.2. PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TB49 - 37
<br />r3al Tub(Bia)
<br />(4. 9 Cu ft)
<br />6.2, PGII
<br />E
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TB14 - 44
<br />Gal Tub(Elio) (.5.9 cu t
<br />6.2, PGII
<br />t
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />ZU
<br />kjal.i
<br />tY
<br />6.2, PGII
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />' TB15 - 20
<br />Gal Tu
<br />(Path) cu t
<br />Z
<br />6.2, PGII
<br />en I
<br />Regulated Medical Waste, n.o.s..
<br />TY15 - 20
<br />tial Tub
<br />(Chemo) (2.7 au ft)
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />PhaL:RaceutiCal Waste
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in proper condition for transport Be ing to applicable international and national gover ental regulations."
<br />i
<br />Prtntew typed Name r Signature
<br />LU4.TRANSPORTER 1 ter -i& Icle, Inc.
<br />41135 West Swift Ave. This is a hcou shipment
<br />a Fresno,Ca 93722
<br />cn
<br />1z TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Cr
<br />~ Print/Type Name ' Signature
<br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS_ Phone #:
<br />5 - - - Applicable Permit Numbers:
<br />Mi
<br />i INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION' Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />„, 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />i 5 w Applicable Permit Numbers:
<br />:c-,
<br />W
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />i
<br />Print/Type Name Signature Date
<br />7. )VREPANCY INDICATION
<br />Transferred containers, cu R to : North Salt Lake; UT
<br />}
<br />9/6/201(
<br />2C. NO. OF 2D. VOLUME
<br />CONTAINERS
<br />Q i
<br />i
<br />1 1 5-
<br />< n
<br />O Date g
<br />Applicable Permit Numbers:
<br />Date
<br />u
<br />8A. Designated Facility:
<br />Sterlcyde Inc -Autodave
<br />4135 W. SWFT AVE
<br />FRESNO,CA 33722
<br />16591 275 - 0994
<br />X31, TSIOST25
<br />TREATMENT FACILI : I
<br />received the ab i
<br />Print/Typo Nam I
<br />o
<br />00. Alternate Facility:
<br />St;ericyde Ina Incineration
<br />90 NORTH 1100 WEST
<br />NORTH SALT LAKE CITY, UT
<br />(gilt) 038 • t 566
<br />TWOST22
<br />that I have been authorized by the
<br />les in accordance with the reqqiw
<br />�F d "M Signature
<br />Irae ao 02-sel,,2010 ORIGINAL
<br />8C. Altemate Facility:
<br />Stericyde Inc-Autodave
<br />1345 Doolittle Drive Ste C
<br />San Lsandro, CA 94577
<br />(5/U) 682-1791
<br />Class V Indneratii n Perrrd# 9
<br />BD. Alternate Facility:
<br />Stericyde Inc-Autodave
<br />2775 E 26TH STREET
<br />VERNON. CA 90023
<br />(22511 Z22 - ZMQ
<br />P6. PA is
<br />to accept untreated medical wastes and that I have
<br />orization. SEP ® 7 2010
<br />Date
<br />
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