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9/24/2010 16:40 Remote ID Imprint ID <br />o'• <br />®®® Stericycle' 9ASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424- 300 <br />®® �ole(vnq PeoRle Red... RIA' <br />Route 0: 301 - 14 <br />D8/1811 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001-10.06•STO <br />MOFROO9007 <br />in <br />ORIGINAL <br />z�aos,ne�.+Rrrc� 9.ea.21 _ ---- <br />I. uCtlCrdtvt s lrarnc, 14(7aress ant? ICICpnuertl rrulrraice <br />ATTN: Caroline Jackson <br />til � III III � I II I I <br />II � I it l III III I III <br />WAGNER BEIGFITS NURSING <br />9289 BRANSTETTER PL REHABILITATION CENTER <br />STOCKTON, CA 95209- 1700 <br />(209) 474-0559 <br />7/26/201( <br />CUSTOMER NUMBER 6020465-002 GENen;ToA-s REGISTRATION tf <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINER TYPE <br />2C, NO. OF <br />2D. VOLUME <br />UN3291. Regulated Medical Waste. n.e.s.. <br />6.2.PGI I <br />T857 - 90 Gal Tub (Bio) (12 cu ft) <br />CONTAINERS <br />Cu FL <br />UN3291, Regulated Medical Waste, n.o.s.. <br />6.2, PGII <br />T94 - 37 Gal Tub (Bias) (9. 9 cu Et) <br />Cu Ft. <br />M <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2. PGII <br />T619 - 99 Gal Tula (Bite) (5.9 9 Cu ft) <br />Cu Ft. <br />Q <br />UN3291, Regulated Medical Waste, n.o.s., <br />T82 - 20 Gal Tub (Bio) (2.7 r u htY <br />6.2, PGII <br />Cu Ft. <br />W <br />Z <br />UN3291, Regulated Medical Waste, n.o.s,. <br />6.2, PGII <br />T1315 - 20 Gal TUb (Path) (2.7 CU rt) <br />Cu Ft. <br />W <br />UN3291, Regulated Medical Waste, n.o.s.. <br />6.2, PGII <br />TY1S - 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 />UN3291, Regulated Medical Waste, n.o.s.. <br />6.2. PGII <br />Cu Ft. <br />Pita rtnaceutlt.al Waste <br />Cu Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® <br />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 TransportTerding to applicable international and national governmental regulations" <br />Printed/Typed Name i' t CJS /1_Qi1 Signature <br />y� <br />Date <br />4. TRANSPORTER 1 ADDRESS: <br />Phone a: (559) 275 _ 0 <br />12 <br />H <br />Stericycle, Inc.. <br />Applicable Permit Numbers: <br />Ca <br />4135 West Swift. Ave. <br />This is Throu h Shipment <br />,N <br />Fresno,Ca 93722 <br />:Z <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />l'- <br />frl*14� V' Q/Y'Y Z( <br />Print Type Name Signature <br />Date <br />5, INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone a: <br />W <br />Applicable Permit Numbers: <br />o� <br />Lu <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Prini/Type Name Signature <br />Date <br />W <br />6. INTERMEDIATE HANDIER 3 / TRANSPORTER 3 ADDRESS- <br />Phone #: <br />w <br />Applicable Pemlit Numbers: <br />OJ <br />Q a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />w= <br />Print/Type Name Signature <br />Date <br />7. DIS EPANCY INDICATION <br />Transferred containers, eu A to : North San Lake, UT <br />3 <br />8A. Designated Facility: 8S. Alternate Faelll 8C. Alternato Facility: <br />9 H= ❑ N: ❑ ry: <br />❑ 8D, Alternate Facility: <br />Stericide Inc -Autodave Stericycle Ino- Incineration Stericycle Int:-Autodave <br />Stericycle Inc -Autodnve <br />4135 W. SWIFT AVE 90 NORTH 1100 WEST 1345 Doolftbe Dillve Sts C <br />2775 E 26TH STREET <br />T1.1 <br />FRESNO,CA 93722 NORTH SALT LAKE CITY, UT San Leandro, CA 94577 <br />VERNON, CA 90023 <br />(559) 275 - 0994 (801) 936 - 1555 (510) 562 - 1781 <br />(323) 362 -3000 <br />! <br />TS31, TS/OST25 TS/OST22 Class V Incineration Pern tt1191 02 P-6, P- i IS <br />! <br />TREATMENT FACILITY: I certify that i have been authorized by the applicable statbage t accept untreated medical wastes and that I have <br />received the above indicwastes in accordance with the requirement outli�int -zation. <br />at <br />c 2Q1® <br />' +3 <br />�-' ✓: , <br />Print/Type Name Signature <br />Date <br />in <br />ORIGINAL <br />z�aos,ne�.+Rrrc� 9.ea.21 _ ---- <br />