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07/05/2011 TUE 10:22 FAX 2009/013
<br />60 MEDICAL WASTE TRACKING FORM NUMBER
<br />• 5tertcycle'
<br />•• IN CASE OF EMERGENCY CONTACT: CHEMTREC 14W424 -WW STANDARD mMIFEST cot•sm
<br />Route 111: 301 - 12 Cu3C=49EQjt4 22fM2 MDFROOAI 3 L
<br />i 1. Generator's Name,ATTN.-Mike ClNumber
<br />Campos III
<br />QAGNER BEIGM NURSING
<br />9289 BRANS'iE'iMM PL R1;MILITATION CRUM
<br />S7bO rmw, CA 95209- 1700
<br />(209) 474-0569 2/7/2011
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<br />CirslvecEriNUMSIM 6020465-002 G TofrsReotsrnaTarea
<br />( J 88. Affemsts Fecithr, ,
<br />2A. DESCRIPTION OF WASTE 28, CONTAINER TYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />3
<br />UN3291, Regulated Medial Waste, n.0s„
<br />6.2.PGt1 T057 - 90 tial Tub (Bio' (12 cu ft)
<br />CONTAINERS
<br />St1erIcyde Inc Incineration
<br />Sterlcyde Inc -Autodave
<br />Stet de Inc -Autodave
<br />Co Ft
<br />4135 W. SWFT AVE
<br />PRE-SNO,CA 53722
<br />UN3291,RegulatedMedical Waste,n.os., TB49 - 37 Gal Tub (Bio)(4,9 cu tt)
<br />6.2, PGII
<br />50 NORTH 1100 WEST
<br />1348 Doo=s Drive Ste C
<br />2775 E 28TH STREET
<br />Cu Ft
<br />1 ®
<br />B 23229681 Regulated Medial Waste, n,o.s, TB14 - 44 Gal Tub (Rio) (5.9 cu tt)
<br />Sen Leandro, CA 94577
<br />5 t 0 562. 1781
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<br />W
<br />T531, T SIOS" r25
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<br />1 Cu Ft
<br />Q
<br />6 2329 1 Regulated Medical Waste, n.o.s., T821 - 20 tial Tub (13a.o) (2.7 Cu ft)
<br />02
<br />P-6. P- t 15
<br />tj
<br />DALE ANNE ORTIZ
<br />Cu Ft
<br />i W6U232299
<br />, Regulated Medial Waste, mo.s., T815 - 20 Gal Tub (Path) (2.7 Gu rt)
<br />II
<br />1
<br />6 23�i1 Regulated Medical Waste, n.os., TY•15 - 20 Gal Tub (Chemo) (2.7 cu ft)
<br />Cu Ft
<br />I
<br />UN3291, Regulated Medical blasts, mos..
<br />• TGCATelehM
<br />Cu Ft.
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.e.s.,
<br />Cu Fl,
<br />6.2. PGII
<br />Pharmaceutical Waste
<br />Cy F.
<br />3. Generator's CertBicatfon; '1 hereby declare that the contents of this consignment are fully and accuratelyT®TAtss ®
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, antl
<br />Cu Ft.
<br />I
<br />are in all respects in proper condition for transport according to applicable international and national governmental regutation;7
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<br />X Printed/iyped Name _ U'�,T k G�t l7 A Z A Signature ruA16--
<br />Date 7 „
<br />I
<br />4. TRANSPORTER 1 ADDRESS:
<br />Stericycle, Inc.
<br />Phone a: (555) 27 - 0
<br />y-
<br />Q a
<br />4135 West Shift Ave.
<br />Applicable Permit Numbers:
<br />a o
<br />2
<br />Freano,Ca 93722 This is a xo gh Shipment
<br />a d
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />~
<br />V. �iL/1�Ytx
<br />? �t
<br />PrinVType Name Signature
<br />Date
<br />3. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS:
<br />Phone It:
<br />N
<br />x
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />W
<br />r
<br />6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone C
<br />w
<br />AppGeeble Permit Numbers:
<br />zINTERMEDIATE
<br />HANDLER /TRANSPORTER CERTIFICATION:
<br />Lux
<br />Recelpt of medical waste as described above.
<br />a $
<br />PrinVType Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Transferred containers, cu ft to . North Salt Lake, UT
<br />y.I
<br />A 6A. Designated FaCglty:
<br />( J 88. Affemsts Fecithr, ,
<br />®8C. Affemate Facafty:
<br />0
<br />81). Alternate Faclft y:
<br />3
<br />Stericyde Inc-Autodeve
<br />St1erIcyde Inc Incineration
<br />Sterlcyde Inc -Autodave
<br />Stet de Inc -Autodave
<br />v
<br />Q
<br />4135 W. SWFT AVE
<br />PRE-SNO,CA 53722
<br />50 NORTH 1100 WEST
<br />1348 Doo=s Drive Ste C
<br />2775 E 28TH STREET
<br />(559) 275 -0994
<br />NOP.T H SALT LAtM CITY, UT
<br />(801 936 - 1555
<br />}
<br />Sen Leandro, CA 94577
<br />5 t 0 562. 1781
<br />( }
<br />VERNON, 817023
<br />(32313fi2 - 3000 '
<br />W
<br />T531, T SIOS" r25
<br />TS/0ST22
<br />Class V Incineration Permit# 9 f
<br />02
<br />P-6. P- t 15
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<br />DALE ANNE ORTIZ
<br />AUTOCLAVED
<br />• TGCATelehM
<br />CA~ /TUI. .
<br />i];� � -�--- ------ __....� •.•,.• • ,---- ---^ •,•••,,••,••.•••, -, ... ••r'r•••••--- �. - -w-,-,yw a—Fu 111—mv 1—ulvau watiteb ana Ural i nave
<br />h received the a bve�ir}dicated wastes in accordance with the requirement outlined in that authorization.
<br />Lull
<br />Print(Type Name
<br />i
<br />van vas
<br />r�6.t 69
<br />Signature
<br />Date
<br />JUL 2 9 2011
<br />t2d 04-FOb2011
<br />_ LIKILONAL
<br />ENTAL HEALTH
<br />PERMIT/SERVICES
<br />
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