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9/24/2010 16:40 Remote ID Imprint ID _ ___ __ __ 5/18 • MEDICAL WASTE TRACKING FORM NUMBER 01000104111, + ®® Stericyt:le' CASE OF EMERGENCY CONTACT: CHEMT1-800.4 REC 300 STANDARD MANIFEST 001.10.06 -STD mor«uq.w1e.eNWnpetrt: Route #: 301 - 10 . MDFRO09RTL 1. Generator's Name, Address and Telephone Number ATTN: Caroline Jackson WAGMR HEIGHTS NURSING 9289 BRANSTETTER PL ITUMILITATIO14 CENTER S`POCKTON, CA 95209- 1700 91IIIBIIS��11116�aI�IBl9pllln�l (Z09) 474-0569 8/16/201( . DISCREPANCY INDICATION CUSTOMERNumeER 6020465-002 GENERATOR'S REGISTRATION If 2A. DESCRIPTION OF WASTE 20, CONTAINERTYPE 2C. NO. OF 20. VOLUME SterIcycie Inc -Autoclave UN3291, Regulated Medical Waste, n.o.s.,CONTAINERS TB57 - '30 Gal Tub (S10) (12 Cu ft) 4135 W. SWIFT AVE 90 NORTH 1100 WEST 1345 Doolbe DrIve Ste C 6.2.PGI1 FRESNO.CA 93722 Cu Ft. VERNON. CA 90023 UN3291, Regulated Medical Waste, n.o.s., TB49 - 37 Gal Tub (Bio) (4.9 Cu !t) (80 1) 938 - 1655 (510) 562 - 1781(323) 362 - 3000 6.2, P611 TS/OST22 Class V Incineration Permits 9t 02 P-6. P-115 Cu Ft. IM UN3291, Regulated Medical Waste, n.o.s., TBI4 - qq Gal Tub (Bio) (5.9 cu Lt) ' S ® 6.2, PGII Signature Date Cu Ft. Q UN3291. Regulated Medical Waste, n.o.s.. TB21 — 20 tial Tub (Ric) (2.1 cu ft) 6.2, PGII Cu Ft. W UN3291, Regulated Medical Waste, n.o.s., T815 — 20 Gal Tub (Path) (2.7 Cts tt) Z 6.2, PGII Cu Ft 5 UN3291 Regulated Medical Waste, n.o.s., 6.2, PGII 1715 — 20 eal Tub (Chemo) (2.7 Cu . ft) Cu Ft. UN3291 Regulated Medical Waste, n.o.s., 6.2, PGI i Cu Ft. UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII Cu Ft. Pharmaceutical Waste R.XA 2— Z lig a. 3 CSA ®' 3 Cu Ft. 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® 2.. • 2. Cu Ft. described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and are in all respects in proper condition for transport ording to applicable international and national governmental regulation " 1PrintedrTyped Name Signature = Date / 4, TRANSPORTER t ADDRESS: Phone #: (55 4) 2!75'— 0 w Stericrc:le, Inc.Applicable Permit Numbers: ~ ¢ o 4135 West Swift AV-. This is ThcQug Shipment € CIL Fresno,Ca 93722 i Q TRANSPORTER CERTIFICATION: Receipt of medical waste as scribed above. cc PrintfType Name •`o �n 0 V, �arrQ Signature Date all / 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phono #: a Applicable Permit Numbers: :oIM )�G 'I INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type, Name Signature Date gApplicable S. INTERMEDIATE HANDLER 3/ TRANSPORTER 3 ADDRESS: Phone a: Permit Numbers: t LU i�F INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. = — Print/Type Name Signature Date . DISCREPANCY INDICATION +—`17`� ,1 _r Ti G Q .JIM_ c - - frlllaetlt>d 12-NJg201®_ ORIGINAL _ --- -- _ 4 Trall►sfe d 1 containers, cu R to : North Salt Lake, UT SA. Designated Facility: Be. Alternate Facility: ® 8C. ARemate Facility: 8D. Alternate Facility: 3 SterIcycie Inc -Autoclave Sterlcycle Into- Indneration Stericyde Inc Autodave Stericyde Inc -Autodave 4135 W. SWIFT AVE 90 NORTH 1100 WEST 1345 Doolbe DrIve Ste C 2775 E 26TH STREET FRESNO.CA 93722 NORTH SALT LAKE CITY, UT San Leandm, CA 94577 VERNON. CA 90023 (559) 276- 0994 (80 1) 938 - 1655 (510) 562 - 1781(323) 362 - 3000 TS31. TS/0ST25 TS/OST22 Class V Incineration Permits 9t 02 P-6. P-115 U C TREATMENT FACILITY: I certify that I have been authorized by the applicable state a �sPj� a j�r�@dical wastes and that 1 have received the above indicated wastes in accordance with the requirement outlined in t t�n!►v r�VIV Print/Type Name Signature Date +—`17`� ,1 _r Ti G Q .JIM_ c - - frlllaetlt>d 12-NJg201®_ ORIGINAL _ --- -- _ 4