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9/24/2010 16:40 Remote ID Imprint ID <br />D 14/18 <br />[p MEDICAL <br />WASTETRACKING FORM NUMBEF <br />®: Sterirytle' IWASE OF EMERGENCY CONTACT: CHEMTREC 1-800-1*00 <br />STANDARD MANIFEST 001.10.WSTO <br />nm�wv+.wt.. e.e.mw tua<: <br />1. Generator's Name, Address and Tele r11 <br />ATTN: Caroline Jackson I11 ill Il III <br />1 it 111111 I I l <br />IRGMM BEIGHTS NURSING <br />9289 BRANSTETTER PL REHABILITATION CETM <br />STOCKTON, CA 95209- 1700 <br />- <br />(209) 474 -05 <br />CUSTOMER NUMBER ' GENERATOR'S REotsTnXn0N # <br />2A. DESCRIPTION OF WA <br />Wo -002 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 F <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />rt) <br />Cu F <br />t <br />UN3291, Regulated Medical Waste, n.o.s., <br />9 cts <br />Q <br />-1 <br />O <br />6.2, PGII <br />. Cu F <br />Q6 <br />Regulated Medical waste, n.o.s..Tatoll <br />44 lt 9t) <br />i <br />2 PGII <br />—20 Gal- Tislat ZZ) <br />Cu F <br />.0 <br />UN3291, Regulated Medical Waste, n.o.s., <br />Z <br />6.2, PGII <br />CUE <br />L <br />'� <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu F <br />UN3291, Regulated Medical Waste, n.o.s., <br />TY15 — ZQ GA1® cu <br />6.2, PGII <br />CU F <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu F <br />Rai 0 2 - 2. a, CP 0.'3, t.0 <br />2 <br />®. Cu F <br />Pharmaceutical Waste <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® <br />3 (p , , j 1 F <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations." <br />X!Printed/Typed Name AEf LLCk, P, Signature <br />Date <br />4. TRANSPORTER 1 ADDRESS: <br />Phone 4: <br />IX <br />Applicable Per er <br />"�'35'9q X175 - 0 " <br />Stericycle, Inc. <br />;y <br />4135 West Swift Ave. <br />Th is is cou h Shipment <br />a <br />TRANSPORTER EEFX1 XWF1317tWpt of medical waste asdes d above. <br />~ <br />V. ���'�- <br />'b jD <br />Print/Type Name t! ° Signal a rZ <br />Date J <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone 4: <br />Applicable Permit Numbers: <br />co <br />W <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />y <br />Print/Type Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone 4: <br />a cc <br />Applicable Permit Numbers: <br />a <br />a <br />INTERMEDIATE. HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />M <br />Print/Type Name Signature <br />Date <br />7REPACY INDICATION <br />8A. Designated Facility: <br />Stertctrde Inc -Autoclave <br />4135 W. SWIFT AVE <br />FRESNO,CA 93722 <br />(559) 275 - 0994 <br />TS31. TWOST25 <br />TREATMENT FACILITY: Ice <br />received the above indicate <br />Print/Type Name <br />81). Alternate Facility: <br />Sberlcyde Ino. Incinereflon SW&yde Inc -Atdoda ve S rIcycle Inc -Autoclave <br />90 NORTH 1100 WEST 1345 DOOM Drive Ste C 2775 E NTH STREET <br />NORTH SALT LAKE 0TY, LIT Salt L wilifiro, CA 94577 VERNON. CA 90023 <br />(801) 936 - 1555 (510) 562 - 1781 (323) 362 - 3000 <br />TS/OST22 ClassV trodnerabori POMM 91 2 P-6, P-115 <br />�( a o d by the applicable state agency to accept untreated medical wastes and that I have <br />1 rda'h a wit t e requirement outlined in that authorization. <br />Signature <br />im <br />Date <br />