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9/24/2010 _16:40 Remote ID Imprint ID D 12/18 1 -
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />• ® Stericyclw �lIrCASE OFff
<br />EM NCY Cp ACT: CHEMTREC 1-800424W-300 STANDARD MANIFEST 001 -10 -06 -STD
<br />®er•® R,,-IV-Pitftd e,.: Route � : 3(11 - I MDFRO09KFT
<br />LU TREATMENT FACILITY. 1 certify that I have been authorized by the applicable state
<br />C received the above indic ed wastes in accordance with the requirement outlined in
<br />Print/Type Nam Signature
<br />0190369
<br />r0tMeMarISM6td 2S,rn-20110 ORIGINAL
<br />to accept untreated medical wastes and that I have
<br />Dale JUN 2 S 2010
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN-. Caroline Jackson
<br />WAGNER HEIGFPTS NURSING
<br />9289 BRANSTETTER PL REHABILITATION CENTER
<br />S'TOCKTON, CA 95209- 1700
<br />(209) 474-0569 6/28/201(
<br />6020465-002
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<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 />T857 - 90 Gal Tub (Bio) (12 cu ft)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />T849 - 37 Gal Tub (Bio) (4.9 Cu '1:t)
<br />6.2, PGII
<br />Cu Ft.
<br />M
<br />UN3291, Regulated Medical Waste, n.os.,
<br />TH14 - 44 Gal Tub (Bio) (5.9 Cu ft)
<br />�1
<br />-G
<br />®
<br />6.2, PGII
<br />1
<br />J 1 Cu Ft.
<br />QUN3291,
<br />Regulated Medical Waste, n.o.s.,
<br />- a o cu
<br />CC
<br />6.2, PGII
<br />Cu Ft.
<br />W
<br />UN3291,Regulated Medical Waste, n.o.s.,
<br />TB1S - 20 Gal Tub (Path) (2-7 cu tt)
<br />6.2. PGII
<br />Cu Ft.
<br />I,Z
<br />UN3291. Regulated Medical Waste, n.os.,-
<br />TY15 - 20_ Gal o)_(2. 7_au_ tt) _ _ _ _ _ _ _ _ . _
<br />-- - - -
<br />- - - - - - - - -
<br />_
<br />6.2,-PGII
<br />_Tub_(Ch
<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 />Pharmaceutical Waste
<br />Cu Ft.
<br />TO G?
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TALS ® - ✓ Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are inall respects in proper condition for transport according to applicable international and national gov nmental regulations"
<br />!!
<br />�&Printed/TypedName Signatu Date 4 2�1 fr0
<br />4. TRANSPORTER IgApDRESS: Phone #: (rj59) 27x5 - 0
<br />Steiricycle, Inc.
<br />CC
<br />CC �M
<br />Applicable Permit Numbers:
<br />4135 West Swift Ave.
<br />a
<br />Fresno,Ca 93722 is is Shipment
<br />a
<br />through
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />~
<br />-Rt-" Q 4 Q
<br />PrinUType Name e f/ Signature Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #:
<br />L l -'c
<br />10
<br />Applicable Permit Numbers:
<br />A �u j
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />e
<br />-
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
<br />.0 a
<br />Applicable Permit Numbers:
<br />Lu
<br />CL
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Q�x
<br />Print/Type Name Signature Date
<br />7. DI REPANCY INDICATION
<br />Transferred containers, cu It to : North Salt Lake, UT
<br />H
<br />BA. DesignatedFacility:
<br />E] 88. Altemate Facility:
<br />® 8C. Altemate Facllltyt
<br />❑ 8D. Altemate Facility:
<br />StariCyde Inc -Autoclave
<br />Steriayrde Ino- Indneradon
<br />Stericyde Inc Autoda ve
<br />Ste firryde Irtc-Autoclave
<br />4135 W. SWFT AVE
<br />90 NORTH 1100
<br />1345 Doolittle Dftve Ste C
<br />7775 E 26TH STREET
<br />LL
<br />FRESNO,CA 93722
<br />NORTH SALT LAKE CITY, UT
<br />San Leandro, CA 94577
<br />VERNON. CA 90023
<br />Z
<br />(569) 276.0994
<br />(80t) 936. 1665
<br />(610) 6132. 1781
<br />(323) 362.3000
<br />W
<br />TS31. TS/OST25
<br />TSIOST22
<br />Class V Indnen tton Penult# 91
<br />02 P-6, P-115
<br />4
<br />LU TREATMENT FACILITY. 1 certify that I have been authorized by the applicable state
<br />C received the above indic ed wastes in accordance with the requirement outlined in
<br />Print/Type Nam Signature
<br />0190369
<br />r0tMeMarISM6td 2S,rn-20110 ORIGINAL
<br />to accept untreated medical wastes and that I have
<br />Dale JUN 2 S 2010
<br />
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