Laserfiche WebLink
9/24/2010 16:40 Remote ID Imprint ID _ _ D 16/18 <br />M�EO�ICAL WASTE TRACKING FORM NUMBER <br />Stericycle' SA -SE OF EM$�GENCY CQNTACT: CHEMTREC 1-600.2 1 STANDARD MANIFEST o01-io-wSTDO0®o00 11 C 840-424-9340 MDFR0096QTRoute f <br />0007 6,c` <br />rPl 2&t�er-2010 ORMINAL_ <br />k <br />1. Generator's Name, Address and Telephone Number III II I!I II III II I I ! If I I I I III Ili f I f II. <br />ATTN: Caroline Jackson <br />WAGNER HEIGHTS NURSING <br />9289 BRANSTETTER PL REHABILITATION CENTER <br />STOCK MN, CA 95209- 1700 <br />(209) 474-0569 <br />3/29/2010 <br />6020465-002 <br />CUSTOMER NUMBER GENERATORIsREGISTRATION# <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />TB57 - 90 Gal Tub (Bio) (12 Cu It) <br />CONTAINERS <br />UN 3291. PG 11 <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.o,s..6.2, <br />TB49 - 37 Gal Tub (Bio) (.9 Cu It) <br />UN 3291, PG II <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />T814 - 44 Gal Tub (Bio) (5.9 Cu It) <br />sy <br />Q <br />UN 3291, PG II <br />Cu Ft. <br />Q <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />_ <br />CC <br />UN 3291, PG II <br />Cu Ft. <br />LU <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />TB1S 20 Gal. Tub (path) (2.7 cu ft) <br />UN 3291, PG 11 <br />Cu Ft. <br />t= <br />REGULATED MEDICAL WASTE, nas..6.2, <br />7Y15 - 20 Gal Tub (Chemo) (2. 7 cu ft) <br />UN 3291, PG 11 <br />Cu FL <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />UN 3291, PG II <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />UN 3291, PG 11 <br />Cu Ft. <br />Pharmaceutical Waste <br />Cu Ft. <br />3. Generator's Certification: "I hereby declare that the Contents of this consignment are fully and accurately TOTALS ® <br />2. ' / . � Cu Ft <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarderl and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations" <br />1 <br />I <br />� <br />3® <br />34430 <br />IPrinted/Typed Name ' /�� Si natu <br />Date <br />4 . TRANSPORTER �tDBt].CjrC1@/ Inc. <br />Phone #: (559) 275 <br />U.1 <br />9135 West Swift Ave. <br />Applicable Permit Numbers: <br />a <br />This is a T ou h hi ent <br />Fresno, Ca 93722 9 <br />i Q <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />~ <br />/�V. � <br />3/,2q/30 <br />Print/Type Name Signature <br />Date <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />i <br />Q <br />Applicable Permit Numbers: <br />iso <br />I = <br />' <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />i j <br />Prinl/Type Name Signature <br />Date <br />i 4 <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />:o <br />Applicable Permit Numbers: <br />°z� <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />a <br />c <br />Print/Type Name Stgnature <br />Date <br />T. DISCREPANCY INDICATION <br />Transferred aomalners, ou n to : North sat! Lake, UT <br />. <br />8A. Designated Facility: C180. Alternate Facility: ® 8C. Altamate Facility: <br />8D. Alternate Facilhy: <br />STERICYCLE INC STERICYCLE INC STERICYCLE INC <br />STERICYCLE INC <br />4135 W. StiMFT AVE 90 NORTH i 100 WEST 9053 NORRIS AVE. <br />2775 E 2M STREET <br />FRESNO,CA 93722 NORTH SALT LAKE CITY, UT SUN VALLEY, CA 91352 <br />VERNON. CA 90023 <br />(659) 275- 0994 (801) 936- 1566 (819) 504 - 8937 <br />(323) 362 - 3000 <br />TS31. TSIOST25 i'SJOS'T22 Claim V Indrteratlon Permit# 91 <br />P-8. P-115 <br />L <br />u <br />c <br />TREATMENT FACILITY: I certify that I have been authorized by the appli ble st ency to accept untreated medical was aRRd �(f, ve <br />received :the above i Ica wastes in accordance with the requi outlin thorization. G LU <br />PrinVType Signature ,.a <br />Date <br />0007 6,c` <br />rPl 2&t�er-2010 ORMINAL_ <br />k <br />