COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

07/05/2011 TUE 10:22 FAX 0008/013 Ak MEDICAL WASTE TRACKING FORM NUMBER^ ! file 0 sterlcycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 141024.23M STANDARD MANIFEST 001.1046-M 0eaetimgrwp6.aw.eMm Route f: 301 - 15 Cun Efta.2Vkj32 MDFROOAK45 _ _ t7 Fttf�241i 1. Generator's Name, Address and Telephone Numt*r AT": !like Campos 61AGM MGM NURSING II tt 1tU1i111 i ii 1 t 1 1 i! li 1!t i lull i 9289 SMIS'i>y"riSR PL MAILITATION CRInSIR S'POI R 01, CA 95209- 1700 jj 1 (209) 474-0569 2/21/2011 ICUSTOMER NUMBER 6020465-002 GENERATORS REb'3Sya TMa 2A- DESCRIPTION OF WASTE 2e. CONTAINER TYPE 2C. NO. OF 20. VOLUME UN329t, Regulates Medical Waste. n.o.s.. 6.2. PGII TH57 - 90 Gat Tub (eio) (12 cu ft) CONTAINERS Cu Ft. UN3291, Regulated Medical Waste, n.o.s.. 6.2. PGII TB4 9 - 37 Gal Tub (Bio) (4. Cu tt) Cu Ft. l M UN3291. Regulated Medical Waste, mos., TB14 - 44 Gal Tub (Bio) (5.9 au ft) 0 6.2, PGII 1 1 Cu Ft 1-' UN3291. Regulated Medical Waste, n.o.s.. _ Cu It 6.2, PGII Cu Ft. W Z UN3291, Regulated Medical Waste, n.os., 6.2, PGII T815 - 20 Gal Tub (Path) (2.7 cu tt) Cu Ft. i W LM3291, Regulated Medical Waste, nos., 6.2, PGII TX3 S - 20 bel xtab (Chemo) ( . 7 cu ft) Ou F 1 Medial Waste, n.o.s., 2911 i i Regulated 6.2. Cu Ft. UN3291. Regulated Medial Waste, n.os., 6.2, PGII Cu Ft. Phamaceutlical Waste Qu R . �^ q 3. Generator's Certification: N hereby declare that the contents of this consignment are fully and accurately TOTALS 1P,7 - ! Cu Ft. described above by the proper shipping name, and are classified, packaged, marked and labetledrptacarded, and are In all respects in proper condition for transport accordlin(/gto tp i blo international and national governmental regulati .Printed/Namo l V Y l ) Typed S' nature Date 4. TRANSPORTER t ADDRESS: Phone it: - Stet ieWle, Inc. u�, U►- tz Applicable Permit Numbers: 4135 alert Swift Ave. in arough hipment Fz-eano, Ce 93722 TRANSPORTER TRANSPORTER CERTIFICATION: Receipt of medical waste as described i 2! tt Prtntlrype Name U- � /Y}'"t� Signature pale S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N: Applicable Permit Numbers: o INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Printrrype Name Signature Date i., a B. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone A: ' r Applicable Permit Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print(Wo Name Signature Date 7, DISCREPANCY INDICATION TrW atamed txilildalners, cu 0 to , North Sit Lake, UT pp BA, Deslgnated Facility: 88, Alternate Faeilky: � 8C. Alternate Facility: 80. Altamate Faculty: St9rlp ds Inc -/1tt Wkn fillo- Indrierabon Slarkyde Inc-AtAodm StairLide InC j 03 4136 W, SW FT AVE 90 NORTH I i QO VYEST 1346 DoAft DOM St11 C 1776 E 2M STREET FRESNO,CA 93722 NORTH SALT LAME CITY, UT Sart Leandro, CA IWT VERNON. CA 2M23 ! (659) 276. MM (Gal) 938. 1566 (610)6132-1781 (21=1362.3MG W TS31, TSJOST26 TSA)= ChWV Ind nand on P^917110 9 I7 P-6, P-115 a W t- TREATMFI�TaFF¢P,�}� TY,•1 i certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have received q{1pye4irtdicated wastes in the in accordance with requirement outlined that authorization. Print t}. s Signature Date i i ORIGINAL