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07/05/2011 TUE 10:22 FAX 12007/013 <br />"etterM® _ EDICAL WASTE TRACKING FORM NUMBER <br />Coe Stericycle'E E ENCY ACT 2t� SI S7p <br />'. Generator's Name Address and Telephone Number <br />A'Ft`i'N; Mike Campos <br />WAGNM BEIGM NURSING <br />9289 BRANSTBTTER PL REHABILITATION <br />j ST'OCrMl, CA 95209- 1100 <br />(209) 474-0569 <br />GUMUER NUHBER 6020465-00 2 GENERATOR'$ REot 7m=N 0 <br />2A. OESCRIP'nON OF WASTE 29. CONTAINERTYPE <br />UN3291, Regulated Medical Waste, n.o.s„ TB57 - 90 tial Tub (Bio) (12 cu ft) <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s., T549 - 37 1 M (8104 79 CU ru <br />I 6.2, PGII <br />1 ® 6U2329" Regulated Medical Waste, n.o.s., - <br />E UN3291, Regulated Medial Waste, n,o.s.. <br />6.2, PGII <br />W UN3291, Regulated Medical Waste, n.o.s., TbIb <br />W 6.2, PGII <br />O UN329it Regulated Medical Waste, n.o.s., 7'Y15 <br />Regulated Medial <br />6.2, PGII - <br />Pharmaceutical Waste <br />.7 cu <br />3/14/2021 <br />2C. NO. OF 213. VOLUME <br />CONTAINERS <br />1 s-9 <br />3. Generator's Certtticatlon: -1 hereby declare that the contents of this consignment are sully and accurately TOTALS l <br />described above by the proper shipping name, and are classified. packaged, marked and labettedtplacarded. <br />are in all respects in proper condition tot transport accords to applicable international and national govern I regulations <br />I I <br />;Printed(Typed Name Signatur <br />4 TR <br />61M <br />Win <br />ANSPOfiTER n p Phone a: t;. -j-7) u <br />tt �LdCIcyc S, Inc. <br />> 41.35 West Swift Ave. Applicable Permit Numbers: <br />a g Fresno,Ca 93722 This is a rouq Shipment <br />a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinUType Name V , Tia Signature Date �4 " <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone N: <br />Applicable Permit Numttets: <br />g INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinVrype Name Signature Date <br />a 5 ft 6. INTERMEDIATE HANDLER 3 J TRANSPORTER 3 ADDRESS: Pie a: <br />c Applicable Permit Numbers: <br />g� <br />�1 a INTERMEDIATE HANDLER !TRANSPORTER CERTIFICATION: Receipt at medical waste as described above. <br />- PrinVrype Name Signature Date <br />7, DISCREPANCY INDICATION <br />Cu <br />Transferred containers, <br />cu A to : North Salt Lake, UT <br />8A. Designated Facility: <br />Inc -Autodeve <br />88. Altemate Facility:8C. <br />Stertcyde Into• indnendlon <br />Attsmate Facility: <br />SterIcIlde inc-Atftciave <br />8D. Alternate Facility: <br />Stsrizyde Inc -Autodave <br />t <br />4135 W, SWFT AVE <br />90 NORTH t 100 WEST <br />1345 DooilMe Drive Ste C <br />2775 E 26TH STREET <br />ua�fStertcyde <br />FRESNO,CA 93722 <br />NORTH SALT LAKE CITY, UT <br />San Leandro, CA 94577 <br />VERNON, CA 90023 <br />(SSS) 275-0224 <br />(6011) 838 - 11585 <br />(51(l) 552 - 11761, <br />(3231362- 3000 <br />TS3 t T SIOST26 <br />DALE <br />TSlOS= <br />01899 V Indrleretion Perfr t# 91- 12 <br />P-6, P- 115 <br />F B�j <br />/GINE ORTIZ <br />AUTOCLAVED <br />W8 <br />TREA'T'MENT 4FACILITY: i certify that i have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />F <br />received the at3ove indicated wastes in accordance with the requirement outlined in that authorization, <br />Print rype,Nalite, Rr <br />Signature <br />Date <br />tp(R#Mr6GS2tM ORIGINAL <br />