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9/24/2010 16:40 Remote ID Imprint ID _ D 7/18 1111. <br />MEDICAL WASTE TRACKING FORM NUMBER <br />000 • ®006 5tericycle' CASE OF EMERGENCY CONTACT: CHEMTREC 1-600.4 00 STANDARD MANIFEST OOI-10.06-STD <br />® <br />Protecting r:oole.Reducing RIW Route #: 301 - 12 MD(' RO09PXL <br />0002273 <br />6'td 2a4k2MO ORIGINAL <br />1. Generator's Name, Address and Telephone Number <br />ATTN: Caroline Jackson <br />i I i 111 II 11 III <br />WAGNER BEIGHTS NURSING <br />9289 BRANSTETTIR PL RKELABILITATION CENM <br />STOCKTON, CA 95209- 1700 <br />(209) 474-0569 8/2/201( <br />CUSTOMER NUMBER 6020465-002 GENERATOR'S REGISTRATION a <br />2A. DESCRIPTION OF WASTE <br />29. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s., <br />T7 - 90 Gal Tub (Bio) (12 cu It) <br />7557 <br />CONTAINERS <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste. n.o.s.. <br />TE49 - 37 Gal Tub (Bio) (4. 9 cu it) <br />6.2, PGII <br />Cu Ft. <br />r <br />UN3291, Regulated Medical Waste, n.o.s., <br />TB14 - 44 Gal Tub (Bio) (5.9 cu It) <br />a <br />6.2, PGII <br />- Cu Ft. <br />a <br />UN3291, Regulated Medical Waste. n.o.s.. <br />T1121 - 20 Gal Tub (Blo) (2.7 C1 t) <br />r. <br />6.2, PGII <br />Cu Ft. <br />1J <br />UN3291, Regulated Medical Waste, n.o.s., <br />TB15 - 20 Gal Tub (Path) (2.7 cu It) <br />Z <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Ty.15 - 20 Gal Tub (Chemo) (2-7 7 cu ft) <br />Cu FL <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, PGII <br />Cu R. <br />Pharmaceutical Waste <br />CuF. <br />G� <br />3. Generator's Certification: "I hereby declare that the contents o1 this consignment are fully and accurately T®TALS No. t - ® Cu Ft. <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 tragsport according to pplicable inte4national and national governmental re I <br />J <br />vt�A <br />HAPrinted/Typed abdo - <br />Name SignatureIt r Date <br />4. TRANSPORTER 1 ADDRESS: Phone fi: (559) 2f51- 0 <br />W <br />Stesieycle, Inc. Applicable Permit Numbers: <br />l� <br />4135 heat Swift Av-e. <br />is is Tits®ug Shipment <br />Fsesno,Ca 93722 <br />Q <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />~ <br />i <br />7?e,3,7&y' q 2 1 d <br />Print/Type Name l ��Y�- Signature Date <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone 4: <br />Applicable Permit Numbers: <br />a s <br />w� <br />s <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print(Type Name Signature Date <br />w <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone k: <br />ii w <br />Applicable Permit Numbers: <br />of <br />=2 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />us <br />Print/Type Name Signature Date <br />i. DISCREPANCY INDICATION <br />Transferred wlilitalnm, cu fl to = North Sail Lake, UT <br />BD. Altemate Facility: <br />6A. Designated Facility: 96. Alternate Facility: ❑ 6C. Alternate Facility: ❑ <br />S6er1cyde Ilnc-Autoclave Sted yde Ina' Indneration Stericycle Inc f1UtOdaVe Stericyde Inc-AtJbadave <br />4135 W. SWFT AVE 90 NORTH 1100 VWST 1345 Doolittle Drive Ste C 2776 E 26TH STREET <br />A <br />FRESNO,CA 93722 NORTH SALT LAKE CITY, UT San Leandro. CA 94577 VERNON, CA SM23 <br />(559) 275 - 0994 (110 1) 936 - 1555 (310) 562 - 1178t (323) 362 - 3000 <br />3 <br />TS31, TS/OST25 TSJOST22 Class V 1 nt9rteratlon PetTrIt# 91 02 F-6, P-11 15 <br />ri <br />TREATMENT FACILITY: I lily at I have been authorized by the applicable a age accept untreated medical wastes and that 1 have <br />- <br />received the above M20ffmd wxTV§ in accordance with the requirement in tha rization. AUG o 204Prtnt/lype <br />Name Signature moi/ Date <br />0002273 <br />6'td 2a4k2MO ORIGINAL <br />