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9/2_4/2010 16:40 Remote ID Imprint ID ❑ 10/18�'I <br />MEDICAL WASTE TRACKING FORM NUMBER <br />®® Stericycle' CASE OF EMERGENCY CONTACT: CHEMTREC 1. W 42 00 STANDARD MANIFEST 001-10-WSTD <br />•. Route #: 301 - 15 MOFRO09MIT <br />1. Generator's Name, Address and Telephone Number <br />ATTN: Caroline Jackson <br />WAGNER HEIG rrS NURSINSY <br />9289 BRANSTETTER PL REEIMILITATION CETM <br />ST`OCRTow, CA 95209- 1700 <br />91181VII�IIBIIIB�BI�1a91118BN11 <br />(209) 474-0569 <br />CUSTOMER NUMBER 6020465-002 GENEamon•s RECIsTRAnoN# <br />2A. DESCR1PnON OF WASTE 2e. CONTAINER TYPE <br />2143291: Regulated Medical Waste, n.os., TBS7 - 90 Gaal Tub (Bio) (12 an ft) <br />Medical Waste, n.o.s. <br />UN3291, Regulated Medical Waste, n.o.s. <br />6.2, PGII <br />Pharmaceutical Waste <br />TB49 - 37 Gal Tub (Bio) (4.9 Cu ft) <br />TB14 - 44 Gal Tub (Bio) (5.9 Cu ft) <br />TB21 - 20 Gal Tub(Bio) (2.7 cu ft) <br />TB15 - 20 Gal Tub (PaCh) (2.7 Cu Lt) <br />TY15 - 20 Gal Tub (Chemo) (2.7 cu ft) <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I v I H <br />described above by the proper shipping name, and are class' ' ,packaged, marked and labelled/placarded, and <br />are in all respects in proper conditt or ransport accords t applicable international and national governmeyj0eg ions- k <br />�-1 a <br />PrintedfTyped Name ` / Signature <br />4. TRANSPORTER 1 ADDRESS: <br />Stericycle, Inc. <br />a o 4135 West Swift Ave. is Th <br />MA Fresno, Ca 93722 <br />E <br />Ch <br />a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Ix <br />~ Print/Type Name �'� r ' �� a' Signature <br />h Shipment <br />7/12/2b1( <br />2C. NO. OF 2D. VOLUME <br />CONTAINERS <br />I <br />t <br />9W <br />Date -111=0 <br />Phone n: (559) - 0 <br />Applicable Permit Numbers: <br />Date _ <br />UN3291, Regulated Medial Waste, n.os. <br />Phone #: <br />6.2. PGII <br />a: <br />UN3291, Regulated Medical Waste, n.o.s. <br />0 <br />6.2, PGII <br />Q <br />UN3291, Regulated Medical Waste, n.os. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above_ <br />6.2. PGII <br />W <br />UN3291. Regulated Medical Waste, n.o.s. <br />Z <br />6.2, PGII <br />0 W <br />2143291, Regulated Medical Waste, n.os. <br />or�r <br />Medical Waste, n.o.s. <br />UN3291, Regulated Medical Waste, n.o.s. <br />6.2, PGII <br />Pharmaceutical Waste <br />TB49 - 37 Gal Tub (Bio) (4.9 Cu ft) <br />TB14 - 44 Gal Tub (Bio) (5.9 Cu ft) <br />TB21 - 20 Gal Tub(Bio) (2.7 cu ft) <br />TB15 - 20 Gal Tub (PaCh) (2.7 Cu Lt) <br />TY15 - 20 Gal Tub (Chemo) (2.7 cu ft) <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I v I H <br />described above by the proper shipping name, and are class' ' ,packaged, marked and labelled/placarded, and <br />are in all respects in proper conditt or ransport accords t applicable international and national governmeyj0eg ions- k <br />�-1 a <br />PrintedfTyped Name ` / Signature <br />4. TRANSPORTER 1 ADDRESS: <br />Stericycle, Inc. <br />a o 4135 West Swift Ave. is Th <br />MA Fresno, Ca 93722 <br />E <br />Ch <br />a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Ix <br />~ Print/Type Name �'� r ' �� a' Signature <br />h Shipment <br />7/12/2b1( <br />2C. NO. OF 2D. VOLUME <br />CONTAINERS <br />I <br />t <br />9W <br />Date -111=0 <br />Phone n: (559) - 0 <br />Applicable Permit Numbers: <br />Date _ <br />001:i010 <br />rptRtoMsirt505261d gB,Ii�2010 ORIGINAL <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />W. <br />Applicable Permit Numbers: <br />-o <br />5W <br />cc <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above_ <br />- <br />Print/Tj pe Name Signature <br />Data <br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />j g <br />Applicable Permit Numbers: <br />$winin <br />s <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />a <br />Date <br />Print/Type Name Signature <br />7. DISCREPANCY INDICATION <br />TraMfemid containers, cu Q to : North Sall Lah, UT <br />8A. Designated Facility: 88, Alternate Facility: ® SC. Alternate Facility: <br />BD. Alternate Facility: <br />3 <br />Sberlcyde Inc-Autodave SbubWde Ince Indnerafion Sterlcyde Inc -Autoclave <br />Sterltyda Inc -AubDdave <br />4135 W. SIMFTAVE 90 NORTH 1100 1345 D001IMS Df1Me Ste C <br />2775 E 26TH STREET <br />FRESNO.CA 93722 NORTH SALT LAKE CITY, UT Son Leandro, CA 94577 <br />VERNON. CA 90023 <br />(559) 275 - 0994 (80 1) S38 - 1555 (5 10) 582 - 1761 <br />(323) 362 - 300D <br />L <br />U <br />TS3 1. TSIOST25 TSMT22 ClassV Indneredon PerrrtV91 <br />02 P-8, P -11b <br />a� <br />Li a <br />TREATMENT FACILITY. I certify that I have been authorized by the applicable state agency ntreated medical wastes and that I have <br />�Aq�ept <br />received the above indicated wastes in accordance with the requirement outlined' thata <br />✓ <br />U !1 I®f0 <br />'F <br />Print/Type Name Signature <br />Date <br />�® <br />001:i010 <br />rptRtoMsirt505261d gB,Ii�2010 ORIGINAL <br />