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9/24/2010 16:40 Remote ID
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<br />Impr_in_t ID D 11/18111
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />OUAeSOj&M NCY CIFACT. CHEMTREC I -M 42 300 STi�ryglr3Pl�t61d?,T ?j?0"o6-STD
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<br />1101 0 CC,t [Z ? 7,
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN: Caroline Jackson 1 `I I I mill 11111
<br />SAGNER HEIGHTS NURSING
<br />9289 BRANSTETTER PL REMBILITATILON CENTER
<br />STOCKMN, CA 95209- 1700
<br />(209) 474-0569 7/5/201(
<br />6020465002 -' 2
<br />CUSTOMER NUMBER GENERATOws REcusTRAmoN x
<br />2A. DESCRIPTION OF WASTE
<br />2B- CONTAINER TYPE
<br />2C. NO, OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TB57 — 90 Gal Tub (Bio' (12 cu Lt)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu FL
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TB — 47 Gail TUb =011cu
<br />6.2. PGII
<br />Cu Ft.
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<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />6.2, PGII
<br />Cu Ft.
<br />QUN3291,
<br />Regulated Medical Waste, n.o.s.,
<br />20 Oat Tftfillim) (2-7
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<br />6.2, PGII 1
<br />Cu Ft.
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<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />W
<br />6.2, PGII
<br />Cu FL
<br />Regulated Medical Waste, n.o.s.,
<br />TY15 — 20 tial Tub (Chemo) (2.7 Cu ft)
<br />6.�I
<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 FL
<br />Pharmaceutical Wast
<br />QM Ft
<br />3. Generator's Certification: "1 hereby declare that the contents of this consignment are fully and accurately TOTALS ® l S .- Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and Iabelled/pfacarded,�regul
<br />are in all respects in proper condition for transport aocordi to applicable international and national governm
<br />Printed/Typed Name Signature
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<br />4, TRANSPORTER t A DRESS: Phone N: —
<br />S�eYiCyC1e, InC.
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<br />Applicable Permit Numbers:
<br />4135 West Swift Ave_
<br />This is a Through shipment
<br />Fresno, Ca 93722
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<br />TRANSPORTER t�'E F(:AT1t7N: Receipt of edical waste as described above.
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<br />PrintfType Name Signature Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone f+:
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
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<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone rt:
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />—
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />Tramferred oofflatners, w R to , North Safi Lake, UT
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<br />slgnated Facility: 0 8B. Affemsta Facility: ® 8C. Alternate Facility: 813. Alternate Facility:
<br />Sbertcyde Inc-AuUDdwe Sterkyde Im Indnernflon Stsricyde Inc -Aubodave Steric/de Inc -Autoclave
<br />4135 W. SWIFT AVE 90 NORTH 1100 AEST 1345 a DM Ste C 2775 E 28TH STREET
<br />FRESNO,CA 93722 NORTH SALT LASE CITY, T San Leandro, CA 94977 VERNON. CA 90023
<br />(559) 275 - 0994 (801) 938 - 1555 (5 t 0) 562 - 1781 (323) 362 - 3000
<br />z
<br />TS31. TSFOST25 TS/OST22 Class V lndnendlon PermV 91 (12 P•6, P-1 15
<br />uJ
<br />PHTREATMENT
<br />w
<br />Imo—
<br />FACILITY: I erti that I have been authorized by the applicable state agenc o accept untreated medical wastes and that I have
<br />received the abov ed es in accordance with the requiremA�O�tliin th rization.
<br />v JUL 0 8 2010
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<br />Print/Type Name Signature Date
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<br />1101 0 CC,t [Z ? 7,
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