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9/24/2010 16:40 Remote ID Imprint ID _ _ _ _ 9/18 IIIIIL_ <br />MEDICAL WASTE TRACKING FORM NUMBER <br />e <br />®®®®00 <br />®®® S�tericycle' CASE OF EMERGENC�CONTA�CTCHEMTREC <br />1-800-424931)0 STANDARD MANIFEST DOI-10-0e-STD <br />1 Generator's Name Address and Telephone Number <br />v <br />ORIGINAL <br />M <br />ATTN: Caroline Jackson <br />" Ilii iii li li 111111111 <br />illi I iii liI illi it <br />WAGNER HEIGHTS NVRSrNG <br />9289 BRAN STE'r PL REHABILITATION CENTER <br />STOCKTON., CA 95209- 1700 <br />(209) 474-0569 <br />GENERATOR'S REGISTRATION B <br />CUSTOMER NUMBERw002 <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 />CONTAINERS <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste. n.o.s., <br />6.2, PGII <br />TB49 - 37 tial Tub jBiol (4.9 Cu ft <br />Cu Ft. <br />Q <br />UN3291, Regulated Medical Waste, n.o.s., <br />11 <br />PGII <br />B - 44 Gal Tub Bio 5. 9 Cu ft) <br />Cu FL <br />Q6.2, <br />= <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />T921 - 20 Gaal Tub (Bio) (2-7 Cu ft) <br />Cu Ft. <br />W <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />TB15 - 20 Gal Tub Path 2.7 cu ft <br />Cu Ft. <br />tZ <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu FL <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu FL <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu FL <br />u FL <br />hASMA-gaii-1=10al Waste, <br />3. Generator's CerdOcation: "I hereby declare that the contents of this consignment are fully and accurately T®TALS 0- <br />q <br />f S' / Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/piacarded, and <br />are in all respects in proper condition or t nsporl accordin licable international and national g2vernmentai ula " <br />` <br />9® <br />. Printed(lyped Name Signature <br />A <br />Date i <br />°CrtSrt�idA <br />4. TRANSPORTER 1 ADDRESS: <br />Phone #: <br />Applicable Per e o75 - 0 <br />} � <br />Stt3C].CyCle, IAC. <br />0 <br />2 a <br />4135 West Swift Ave. <br />This is Thr o h Shipment <br />U) <br />722 <br />a Z <br />TRANSPORTERP CCmhTIF l6f)0 : Receipt of medical waste as doscribed above. <br />~ <br />Print/Type Name yy Signature <br />Date aF 0 <br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Phone #: <br />Ile <br />Applicable Permit Numbers: <br />a <br />=wc <br />Z �= <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />_ <br />Print/Type Name Signature <br />Date <br />h w <br />6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: <br />Phone #: <br />_y g <br />Applicable Permit Numbers: <br />xWJ <br />i <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 />Imixed Aft to* North <br />T <br />6A. Designated Facility: 86. AltemafTFticlltty: C. Alternate Facility: <br />8D. Alternate Facility: <br />e <br />Sta qde Inc-Autodays Stedwde Ino- Indn on Stelicide Inc -Autodave <br />,Stulcycle Inc-Auloctave <br />4135 W. SWFI'AVE 90 NORTH 1100 1346 Do41R31e Drive Ste C <br />2776 E 28TH STREET <br />FRESNO,CA 93722 NORTH SALT LAKE CITY, LIT San Leandro, CA 94577 <br />VERNON, CA 90023 <br />W �'N <br />R <br />( 559) 275 - 0994 (801) 936 - 1555 ("S 10) 562 - 1781 <br />Class PemiN 9102 <br />(323) 362 - 3000 <br />P-6, P-115 <br />TS31, TWOST25 TS/OST22 V tndnerabon <br />1a <br />Q.- <br />Cr <br />TREATMENT FACILITY• ce ' that I have been authorized by the applica�ye-State at to accept untreated medical wastes and that I have <br />i ion. <br />I- L <br />received the ab tate stes in accordance with the requirement u-111nc. <br />n <br />t <br />JUL 19 2®SQ <br />Print/Type Name Signature <br />Date <br />v <br />ORIGINAL <br />M <br />