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9/24/2010 16:48 Remote ID Imprint ID _ _ D 13/18 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />®®® Steriicyde' OF EM NCY C ACT: CHEMTREC 1-1300-024- 300 STANDARD MANIFEST 001.10-0&STD <br />®® noe«m+orwp.aedvayal,a ?AtE <br />ua �: ^ MDFROO9I9I <br />,.Generator's Name, Address and Telephone Number SII II iI IIf I {IIIIi I ! ItI I III I <br />ATThI: Caroline Jackson <br />WAGNER HEIGHTS NURSING <br />9289 BRANSTETTER PL REHABILITATION CENTER <br />STOG'KTON, CA 95209- 1700 <br />(209) 474-0569 - 6/14/201( <br />CUSTOMER NUMBER 6020465-002 GENERATOR'S REGISTRATIONtI <br />2A. DESCRIPTION OF WASTE 2B• CONTAINER TYPE <br />6U232291 Regulated Medical Waste, n.o.s., TB57 — 90 Gal Tub (Bio) (12 cu ft) <br />. PGII <br />UN3291 Regulated Medical Waste nos TB49 — 37 Gel Tub (B (i) (4.9 Cu ft) <br />6.2. PGII <br />fY UN3291, Regulated Medical Waste, n.o.s., TB14 — <br />® 6.2, PGII <br />QUN3291, Regulated Medical Waste, n_o.s., <br />Q 6.2, PGII <br />W UN3291, Regulated Medical Waste, n.o.s., TBTF-- <br />tZ 6.2, PGII <br />ll <br />SLIlIkPi <br />WAK-1 1 <br />UUN3229G11I Regulated Medical Waste, n.o.s., TY15 — 20 Gal Tub (Chemo) (2.7 cu <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s., <br />Pharmaceutical Wa <br />3. Generator's Cerdtication: "1 hereby declare that the contents of this consignment are fully and accurately TOTALS <br />described above by the proper shipping name, and are classified, packaged, marked and tabelled/placarded, and <br />are In all respects in proper condition tot trgnspoit accordinKo Vkicabie international and national gov,#rnmenlal regulations" <br />I IPrinted/Typed Name <br />W 4. TRANSPORTER 1 .Verlc�yc-le, Inc. <br />uj <br />40135 West Swift Ave. <br />a Fr 9no,Ca 93722 <br />LZ Q TRANSPORTE FICATION I me( <br />This is a Through Shipment <br />2C. NO. OF 12D. VOLUME <br />CONTAINERS <br />Cu <br />6 <br />Date ��® <br />Phone N: <br />Applicable Permit Numbers_ <br />Date <br />S. INTERIVIMI*E RANDLER 2 /TRANSMTITEVAPDRESS: v v <br />Phone #: <br />ia <br />Applicable Permit Numbers: <br />:®g <br />;Ujo <br />( <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/type Name Signature <br />Date <br />Ui <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone p: <br />i g w <br />Applicable Permit Numbers: <br />LU <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Printrrype Name Signature <br />Date <br />INDICATION <br />Transferred containers, CU 8 to' North Sah Lake, UT <br />17.7DISCJKNCY <br />BA. Designated Facility: 8B. Alternate Facility: ® 8C. Alternate Facility: <br />® 8D. Alternate Facility: <br />:t <br />Sterityde Inc -Autodave Steiicyde Ina- incineration Stericycle Inc -Autodave <br />Stsricyde Inc -Autoclave <br />4135 W. SWIFT AVE 90 NORTH 1100 WEST 1345 Doolittle Drive Ste C <br />2775 E 26TH STREET <br />6 <br />FRESNO,CA 93722 NORTH SALT LAKE CITY, UT San Leandro. CA 94577 <br />VERNON, CA 90023 <br />(559) 275 - 0994 (80 11) 936 - 1555 (510) 562 - 1781 <br />(323) 362 - 3000 <br />U <br />TS3 1. TS/OST25 TSIOST22 Class V Intirlen*or1 Perrnit3! <br />91 02 P-6, P-1 15 <br />ifly <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />- <br />received the above in to stes in accordance with the requirement out�ii,ation. <br />JUN 14 2I)1D <br />Print/Typa Name.Signature <br />Date <br />ALk <br />rptRsMatr6=Md 1Wun-2010 ORIGIN <br />