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9/24/2018 16:49 Remote ID Imprint ID <br />4*0 Stericycle' <br />• ft*•N^9►acW. RWkn wk: <br />IfCASE OF EMERGENCY CONTACT: CHEMTREC <br />Route 9: 301 12 <br />_ ® 3/18 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />'STANDARD MANIFEST 001.10.06 -STD <br />MDFRO09U5I <br />0 0 t <br />Id <br />ORIGINAL <br />itrlG2riA _� w ... 'iA�A <br />1. Generator's Name, Address and Telephone Number <br />ATTN: Caroline Jackson <br />WAGNER HEIGHTS NURSING i <br />9289 BRANSTETTER FL YTAMILITATION CENTER <br />STOCK'iYIN, CA 95209- 1700 <br />209) 474-0569 <br />8/30/201(. <br />CUSTOMER NUMBER 6020 Q 65-002 GENERATOR'S REGISTRATION 0 <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINEERTYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s., <br />CONTAINERS <br />6.2, PGII <br />T857 - 90 Gal Tub (Bio) (12 cu ft) <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n,o.s„ <br />6.2, PGII <br />TB49 - 37 Gal Tub (Rio) (4. 9 cu ft) <br />Cu Ft. <br />CC <br />0 <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2,PGI1 <br />TB14 - 44 Gal Tub(Bio) (5.9 Cu ft) <br />Jr. <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2. PGII <br />T821 - 20 Gal Tub (Bio) (2.7 cu ftp <br />CC <br />Cu Ft. <br />W <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />T815 - 20 Gal Tub (path) (2.7 cu fit) <br />Cu Ft. <br />W <br />0 <br />UN3291. Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />TY15 - 20 Gal Tub (Chemo) (2.7 Cu ft) <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN329t, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />all ma-ite.1 <br />C <br />3. Generator's Certification: 'I hereby declare that the contents of this consignment are fully and accurately <br />TOTALS ® <br />Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/plecarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental <br />r ions." <br />';wKA Jimh <br />,Printed/rypedName Signature <br />Date <br />a: <br />4. TRANSPORTER 1 ADDRESS: <br />Phone k: (559 275 - 0 <br />UJI <br />Stericycle, Inc. <br />Applicable Permit Numbers: <br />a rx <br />o <br />�o. <br />4135 West Swift Ave. <br />This is a hrough Shipment <br />to <br />Fresno, Ca 93722 <br />y Q <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Y, ��vry-ei <br />8 G� <br />Print/Type Name _ Signatura <br />Date <br />5_ INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Phone #: <br />t 5 Q <br />Applicable Permit Numbers: <br />>�c <br />51 � <br />g <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Prinl/Type Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />i g w <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />- <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />to : North Salt Lake UT <br />A. Designated Facility: ® 913. Attamate Facility: 6C. Attemate Facility: <br />L] 81D. Attemate Facility: <br />'- <br />Stericycle Inc -Autodave Steficyde Ina Indnerafion Stericyde Inc Autodave <br />Stericyde Inc -Autodave <br />4135 W. SWIFT AVE 90 NORTH 1100 WEST 1345 Doolittle Drtve Ste C <br />27751- 26TH STREET <br />FRESNO,CA 33722 NORTH SALT LAKE CITY, UT San Leandro, CA 94577 <br />VERNON. CA 90023 <br />(559) 275 - 0994 (801)936- 1555 (510) 562 - 1784 <br />(323) 362 - 3008 <br />' <br />TS3i , TS/OST23 TSIOST22 Class V Incineration Perrrtt # 9 <br />02 P-6, P 115 <br />u <br />c <br />- <br />TREATMENT FACILITY: I rtify 4hat 1 have been authorized by the applicable stale agency accept untreated <br />'n <br />medical wastes and that I have <br />received the above In s in accordance with the requirement outlin that ization. <br />AUG $ ®2010 <br />Print/Type Name Signature ; <br />Date <br />0 0 t <br />Id <br />ORIGINAL <br />itrlG2riA _� w ... 'iA�A <br />