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9/24/2010 16:40 Remote ID_ Imprint ID _ D 15/18 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />®• Stericycle' *ASE OF EMERGENCY CONTACT: CHEMTREC 1-800-2351 STANDARD MANIFEST 001.10.06 -STD <br />'•' ftWa.V'"°r°s.M*.d" '" Route #: 301 - 13 cHEmTREc 800-4.24-9300 MDFR0097QM <br />1. Generator's Name, Address and Telephone Number <br />ATTN: Caroline Jackson <br />RIAGNER BEIGH175 NURSING <br />9289 BRANSTETTER PL PYAiABiLITATION CE14TER <br />STOCKTON, CA 95209- 1700 <br />(209) 474-0569 <br />4/5/2010 <br />CUSTOMER NUMBER 6020465-002 GENERATOWs REGISTRA71110 Ntf <br />2A. DESCRIPTION OF WASTE 120. CONTAINER TYPE 2C. NO. OF 12D. VOLUME <br />CONTAINERS <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, TB57 - 90 tial Tub (Bio) (12 cu ft) <br />UN 3291, PG II _ Cu Ft. <br />REGULATED MEDICAL WASTE, n.o.s..6.2,I TB49 - 31 Cal Tub (Bio) (4. 9 Cu ft) <br />UN 3291, PG II ` <br />TD14 - 44 rat Tub(Bio) (5.9 CU ft) <br />TB15 - 20 Gal Tub Oath) (2.7 eu tt) <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 TOTALS <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 />_ _.. i / J . <br />REGULATED MEDICAL WASTE, n.o.s.,6. <br />Q <br />UN 3291, PG II <br />REGULATED MEDICAL WASTE, n.o.s..6. <br />4 <br />I= <br />UN 3291, PG II <br />REGULATED MEDICAL WASTE, n.o_s..6. <br />W <br />W <br />r0 <br />UN 3291, PG II <br />REGULATED MEDICAL WASTE, n.o.s..6. <br />UN 3291, PG II <br />REGULATED MEDICAL WASTE, n.o.s.A <br />a <br />UN 3291, PG II <br />REGULATED MEDICAL WASTE, n.o.s..6. <br />~ <br />""a Y ���Q+ <br />UN 3291, PG II <br />Pharmaceutd;cal Waste <br />PrinVType Name °�' Signature <br />TD14 - 44 rat Tub(Bio) (5.9 CU ft) <br />TB15 - 20 Gal Tub Oath) (2.7 eu tt) <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 TOTALS <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 />_ _.. i / J . <br />17. DISCREPANCY INDICATION <br />Transtenred containers, <br />�. <br />I IPrintedlryped Nama-.�166z4k� Si natu <br />Date qoin 10 <br />11 8B. Alternate Facility: <br />4. TRANSPORTER 1 ADDRESS: <br />Phone #: (559) 275r- 0 9 <br />IX <br />Stericycle, Inc. <br />Applicable Permit Numbers: <br />4135 W. SWFT AVE <br />9135 West Swift Ave. This is a cough hipment <br />90 NORTH 1100 VVEST <br />n. <br />Fresno, Ca 93722 <br />a <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />(559) 275 - 0994 <br />~ <br />""a Y ���Q+ <br />S �® <br />TS31, TS/OST25 <br />PrinVType Name °�' Signature <br />Date <br />to <br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Phone #: <br />Y <br />� a <br />Q <br />Applicable Permit Numbers: <br />UJI <br />TREATMENT FACILITY: I certify that I have been authorized by the appli <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />received the above Indicate <br />- <br />Print/Type Name Signature <br />Date <br />d¢ <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone ft: <br />Permit Numbers: <br />Lu <br />Q J <br />R s ' <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Applicable <br />z�a <br />Q- <br />Print/Type Name Signature <br />Date <br />17. DISCREPANCY INDICATION <br />Transtenred containers, <br />�. <br />8A. Designated Facility: <br />STERICYCLE INC <br />11 8B. Alternate Facility: <br />J <br />STERICYCLE INC <br />SUN VALLEY, CA 91352 <br />STERICYCLE INC <br />L) <br />4135 W. SWFT AVE <br />Class V Indnerabon Pgmit# 91- <br />90 NORTH 1100 VVEST <br />a <br />FRESNO,CA 93722 <br />NORTH SALT LAKE CITY, UT <br />_ <br />(559) 275 - 0994 <br />(801) 936- 1555 <br />Z <br />TS31, TS/OST25 <br />TSIOST22 <br />to <br />� a <br />Q <br />UJI <br />TREATMENT FACILITY: I certify that I have been authorized by the appli <br />h - <br />received the above Indicate <br />was s in accordance with the requirernSgk <br />=, <br />Print/Type Name <br />,p�'Q� l� Signature <br />ou ft to : North Salt Lake, UT <br />8C. Alternate Facility: <br />Q 8D. Alternate Facility: <br />STERICYCLE INC <br />STERICYCLE INC <br />9053 NORRIS AVE. <br />2775E 26TH STREET <br />SUN VALLEY, CA 91352 <br />VERNON. CA 90023 <br />(8 18) 504. 6937 <br />(323) 362 - 3000 <br />Class V Indnerabon Pgmit# 91- <br />2 P-6, P-115 <br />r0R9lA&6052Gd 30 -Mur -21110 ORIGINAL <br />accept untreated medical wastes and that I have <br />Date APR 06 2090 <br />