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07/05/2011 TUE 10:21 FAX 12006/013 MEDICAL WASTE TRACKING FORM NUMBER Awe ♦ Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800 424 -ciao STANDARD MANIFEST 0011•1003,-570 ®® er�.w.egrat CUSTOMER NO.21132 i - - ---Route > -. 301 -- --11 MDFROOAV LCC i. generator's Name, Address and Telephone Number ATTN: Hike Campos fiAGJ,'�R EEIGEn NURSING 9289 EPA14STET ER PL i7LHABILITA7101A STaCRRT3N, t0. 95209- 1700 CusrotwtNumavi k020455-002 G *s REowitArtom0 2A. DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C. NO. OF 20. VOLUME UN3291. Regulated Medical Waste, n.o.s., CONTAINERS 3berly& Inc -Autoclawt 6.2, PGil TB57 - 90 Gal Tub (Bio) (12 cu ft) Stericyds Ilio- IncInwallort Cu Ft. 62.PPCiilReputatedMedicalwazts,n.os., SWdgOe Ina-Autasdva 4135 W. SWIFT AVE T849 - 37 Gal Tub (Rio) (4.9 Cu Lt) 90 NORTH 1100 YYM Cu FL i ,Pp ted Medical Waste, n.o.s., 2775 E 285TH STREET FRESNO.CA 93722 6.2PGO TB14 - 44 Gal Tub (Bio) (5.9 CU Lt) NORTH SALT LAME CITY. UTSon 5 _ Cu R. 6.23291, Regulated Medical Waste, n.o.s- TB21 - 20 Gal Tub (Bio) (2.7 ft} 6.2, PGI! VERNON. CA 2=3 (559) 275-1121 TSft3.ST?2 � z (801) 936 - Is" Cu ft. Regulated Medical waste, n.os.. (323) 362 - 3000 .� 6 2, PGj� T815 - 20 Gal Tub (Path) (2.7 cu et) -36 11i atOST7S T91= 2S Cu Ft. 6.23291, Regulated Medial waste, n.os., l 6.2, PG Ii TY15 - 20 Gal Tub (Chemo) (2.7 cu tt) Cu Ft. UN3291. Regulated Medical Waste, n.o.s., 6.2, PGiI Cu Ft. UN3291, Regulated Medical Waste, n.os., 6.2, PGII Cu Ft. MI'Moccutical to Cu F . 3, Generator's Certification: 'I hereby declare that the contents of this consignment are fully and accurately Cu described attmm hu Iha n nnnr ehinnin norma —A n.,n on—Ir—A n .. -n. A -..a ,..a..u.,.ead-...,.a..w .. Ft. are in all respects in proper condition for transport as ording to applicable international and national governmental regulations' Printedt7yped Name t Sia dc4. TRANSPORTER 1 ADDRESS: Lu Stericycle, Inc. ❑ This is a a0 4135 Rest Swift Ave. a. Freano,Ca 93722 a 2 TRANSPORTER CERTIFICATION: RoWipt of medical waste as described above. °¢' y. PrirIVType Norma t�/)'7rt3. Signature I i v v-- __ Date Ione (559) 275-11 I Shipment Appucaha Permit Numbers: Bauler Reg# 3400 3. NTERMEDtATE HANDLER 2 /TRANSPORTER 2 ADDRESS: N� g INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, PrinVrype Name Signature Date ��- Phone N: Applicable Permit Numbers: Date 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone a: �w Applicable Permit Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature Onto 7. DISCREPANCY INDICATION Transferred canlalners, ori a to : North Salt Lake, UT AM.. Designated Facility: ❑ 86. Alternate Facility: ® SC, Altsmato Facility: 81). Ahemos Facility: 3berly& Inc -Autoclawt Stericyds Ilio- IncInwallort Stetityde Inc-Auioclm SWdgOe Ina-Autasdva 4135 W. SWIFT AVE 90 NORTH 1100 YYM 1345 Dtmt3fife Drke Ste C 2775 E 285TH STREET FRESNO.CA 93722 NORTH SALT LAME CITY. UTSon CA 94377 VERNON. CA 2=3 (559) 275-1121 TSft3.ST?2 � z (801) 936 - Is" (510)50- 2177 (323) 362 - 3000 .� -36 11i atOST7S T91= 2S IEATMENT-FACIL)TY:II Cetiffy that I have been authorized by the applicable State agency to accept untreated medical wastes and that 1 have :e'lved the abbve`fridicated wastes in accordance with the requirement outlined in that authorization. Vrypo Name t r .. 11—Ar, Signature Date