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9/24/2010 16:40 Remote ID Imprint ID _ ❑ 6/18 III <br />e MEDICAL WASTE TRACKING FORM NUMBER <br />®e Stericyde• OASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424 300 STANDARD MANIFEST 001.10 -06 -STD <br />e••..a.• rR6h: . Route #: 301 - 14 NDFR009QQC <br />O&AIo-2010 ORIGINAL <br />T <br />1. Generator's Name, Address and Telephone Number <br />ATTN.- Caroline Jackson <br />I ! I I <br />IIns <br />WAGNER HEIGHTS NURSING <br />9289 BRANSTETTER FL I&MBILITATION CEVTKR <br />STOCrmN, GA 95209- 1700 <br />(209) 474-0569 <br />8/9/201( <br />CUSTOMER NUMBER 6020465-002 GENERATOR'S REGISTRATION 0 <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINER TYPE <br />2C. NO, OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s., <br />TB57 — 90 [sal Tub (Bio} (12 cu ft) <br />CONTAINERS <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />T849 — 37 Gal Tub (Bio) (4.9 Cu ft) <br />6.2. PGII <br />_ <br />Cu Ft. <br />® <br />232291! Medical Waste, n.o.s., <br />TB14 - 44 Gal Tub (Bio) (5.9 Cu ft) <br />3 <br />�• <br />Regulated <br />6 <br />Cu Ft. <br />QUN3291, <br />Regulated Medical Waste, n.o.s., <br />— o <br />cc <br />6.2. PGII <br />Cu Ft. <br />W <br />UN3291, Regulated Medical Waste. n.o.s., <br />TB15 — 20 Gal Tub (Path) (2.7 Cu Lt) <br />Z <br />6.2, PG I I <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s., <br />TY15 — Zp eel Tub (Cb o) (2.7 Cu ft) <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste. n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGI I <br />Cu Ft. <br />Pharmaceutical waste <br />u Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® <br />t �-B <br />3 B , • ® Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labellediplacarded, and <br />are in all respects in proper condition for transport according to applicable international and national govern a tall r gula ' ns! <br />C' <br />o b <br />Prinied/ryped Name Signature <br />Date <br />tx <br />4. TRANSPORTER 1 ADDRESS: <br />Stera.cycie, Inca <br />Phone — <br />w <br />Appli le Permit Numbers: <br />'r o <br />4135 West Swift Ave. is is Throug shipment <br />n. <br />Fresno, Ca 93722 <br />rn <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />cc <br />y• <br />�g <br />Print/Type Name/ et^s-Y"Lj Signature <br />,`D <br />Date <br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Phone }i: <br />a <br />Applicable Permit Numbers: <br />W <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />�— <br />Print/Type Name Signature <br />Data <br />Uac <br />S. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone N: <br />ESLU J <br />cc I <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Applicable Permit Numbers: <br />z <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />TrontmTed 0ontainem. cu A to: North Salt Lake, UT <br />• <br />RA. Designated Facility: $0. Alternate Facility: ® eC. Alternate Facility: <br />E] 60, Alternate Facility: <br />Ste iyde Inc -Auhxim Ino, Indnerallm SWdeyde Inc -AubxMw <br />Inc -Auhxlave <br />l <br />4135 W. SWFT AVE 90 NORTH 1100 VMBST 1345 DW& DrW SDI! C <br />2775 E 26TH STREET <br />FRESNO.CA 93722 NORTH SALT LAKE CITY, UT San Leardm. CA 9457? <br />VERNON. CA 91=3 <br />(359) 2?5 - Q994 (801) WS - 1555 (510) 562 - 1781 <br />(323) 362 - 3000 <br />i <br />7S3 1, TSADST25 V I 91 <br />P-6• P-115 <br />TREATMENT FACILITY: 1 certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that 1,�1�y0 <br />' in the O U 2UlU <br />received the above in ed tes accordance with n. <br />require��� <br />AUG <br />Print/Type Name D/Y �A! t SignatureDate <br />O&AIo-2010 ORIGINAL <br />T <br />