|
9/24/2018 16:48 Remote ID Imprint ID _ _ _ D 17/18
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />•i®® Steritytle'
<br />ASE OF EMERGENCY CONTACT: CHEMTREC 1-800-2 1 STANDARD MANIFEST 001-10•06•STD
<br />• ® P,o, by Fagot. Redudn Risk,'
<br />1. Generator's Name, Address and
<br />ATTN: Caroline Jackson
<br />WAGNER SEIGfiTS NURSING
<br />9289 BRANSTEETTER PL REHABILITATION CEFM
<br />STOCRTON, -CA 95209-- 1700
<br />WASTE,
<br />UN 3291, PG 11
<br />GENERATOR'S REGISTRATION #
<br />CONTAINER TYPE
<br />3. Generators Certification: "I hereby declare that the contents of this consignment are fully and accurately
<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 governments
<br />II
<br />^ i Printed/Nyped Name Signatu
<br />tr 4.TRANSPORTER 1 ADDRESS:
<br />U.11
<br />r tE Stericycler Inc.
<br /><0 4135 West Swift Ave.
<br />� fn Th is is a Th c o h
<br />a a TRANSPORT ;L" medical wast a above.
<br />t•
<br />PrinUType Na Signatu
<br />!�4'w '161'1�
<br />2C. NO. OF '2D. VOLUME
<br />CONTAINERS
<br />Cu
<br />TOTALS ►, ' # Cu FL
<br />!gulatlons." `
<br />Data"
<br />Phone #:
<br />Applicable Pe#5000bt&75 - 0994
<br />IR
<br />Date � —
<br />CUSTOMER N'UNBER _
<br />2A. DESCRIPTION OF WA IND (112
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />UN 3291, PO II
<br />Phone N:
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />11357
<br />�
<br />Permit Numbers:
<br />UN 3291, PG II
<br />CC
<br />REGULATED MEDICAL WASTE, n,o.s.A.2,
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />O
<br />UN 3291, PG II
<br />PrintlType Name Signature
<br />Q
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />tIX
<br />UN 3291, PG II
<br />_
<br />W
<br />REGULATED MEDICAL WASTE, n,a.s-6.2,
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />W
<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.3.,6.2,
<br />Print/Type Name Signature
<br />Date
<br />UN 3291, PG II
<br />_
<br />WASTE,
<br />UN 3291, PG 11
<br />GENERATOR'S REGISTRATION #
<br />CONTAINER TYPE
<br />3. Generators Certification: "I hereby declare that the contents of this consignment are fully and accurately
<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 governments
<br />II
<br />^ i Printed/Nyped Name Signatu
<br />tr 4.TRANSPORTER 1 ADDRESS:
<br />U.11
<br />r tE Stericycler Inc.
<br /><0 4135 West Swift Ave.
<br />� fn Th is is a Th c o h
<br />a a TRANSPORT ;L" medical wast a above.
<br />t•
<br />PrinUType Na Signatu
<br />!�4'w '161'1�
<br />2C. NO. OF '2D. VOLUME
<br />CONTAINERS
<br />Cu
<br />TOTALS ►, ' # Cu FL
<br />!gulatlons." `
<br />Data"
<br />Phone #:
<br />Applicable Pe#5000bt&75 - 0994
<br />IR
<br />Date � —
<br />4
<br />5. INTERMEDIA E HANDLER 2 / TRA S 2 ADCV
<br />Phone N:
<br />N
<br />aApplicable
<br />�
<br />Permit Numbers:
<br />a�
<br />Rag
<br />NJ
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrintlType Name Signature
<br />Date
<br />, w
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />a s
<br />®LU
<br />Applicable Permit Numbers:
<br />N 2 "
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Ir —
<br />Print/Type Name Signature
<br />Date
<br />7. DIS EPANCY INDICATION
<br />9A. Desnated Facility:
<br />,
<br />to F Sall tak's,
<br />8D. Alternate Facility:
<br />v
<br />STERICYCLE INC
<br />STERICYCLE INCSTERICYCLP
<br />INC
<br />STERICYCLE INC
<br />4135 W. SWIFT AVE
<br />90 NORTH 11Aa WEST
<br />9053 NORRIS AVE.
<br />2775 E 2" STREET
<br />Z 11
<br />FRESNO,CA 93722
<br />NORTH SALT LAIC CITY, UT
<br />SUN VALLEY, CA 91352
<br />VERNON, CA 90023
<br />UJI
<br />(559) 275 - 8994
<br />(M 1) 936 - 1555
<br />(816) 504 - 6937
<br />1323, 362 - 3000
<br />TS31, T WOST25
<br />TSI OSM2
<br />Class V Indnet'adon Pemilt# 91-
<br />2 P-6, P-115
<br />W
<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 />t— -
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.®i®
<br />Print/Type Name Signature 4.`
<br />Date
<br />4
<br />
|