Laserfiche WebLink
07/05/2011 TUE 10:21 FAX <br />12005/013 <br />'WMEDICAL WASTE TRACKING FORM NUMBER <br />:®• Stericycte' �INCASE�fEtJIGENCYfgNT :CIHEWREC1•800•4243300 <br />Route MDPt(oVUNtilti fsooaSm <br />3tLIi11 J� CUSTOMER NO. 21132 c tiVUN1Mt35� <br />1. Generator's Name, Address and Telephone Number <br />ATTK : Mike Campos <br />i ZkGKM HEIGHTS NURSING <br />9289 BRANS7ErM PL RIKIMILIT'ATION <br />J STOCKTON, CA 95209- 1700 <br />(209) 474-0569 <br />5/16/2013 <br />i <br />cussaaaattNwffaen 6020465-002 <br />G MA'S ReGtS f 7M e <br />Phone4. <br />2A. DESCRIPTION OF WASTE <br />28, CONTAINERTYPE <br />2C. NO. OF <br />20. VOLUME <br />i <br />6m II Regulated Medial Waste' n.0.s, <br />T057 - 90 Gal Tub (Bio) (12 Cu ft) <br />CONTAINERS <br />TS/OST22 <br />~ <br />UN3291,Regulated Medical Waste, e•o.s., <br />T049 - 37 rsa1 Tub ( b)T479 CU <br />TREATMENT FACILITY: ice <br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />? <br />62. PGII <br />PrsMJType Name <br />6 23291. Regulated Medical waste, mo.s., <br />T014 - 44 Galt o eu <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />j <br />O <br />. Poll <br />t <br />' <br />. <br />? Q <br />UN3291. Regutated Medical waste, n.o.s., <br />TOZZ - 20 1511 <br />Pie q; <br />W <br />cc <br />62. PGiI <br />S a c <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste a$ described above. <br />I <br />' W <br />UN329t, Regulated Medical Waste, n.o.s.. <br />T1115 - Ga T a c <br />P intrrypo Name Signature <br />W6.21 <br />PGII <br />?.DISCREPANCY INDICATION " ��fifffvd 2 ttl <br />t�aUeis, , dl A to ; North Salt Lake. ui <br />r� <br />UN3291, Regulated Medical Waste, n,os, <br />62, PGII <br />T�'15 - 20 Gal Tub (Chemo) -(2. 7 cu tt) <br />j <br />UN3291, Regulated Medical Waste, <br />6.2. PGII <br />UN3291, Regulated Medical waste, e.04.. <br />6.2.PGII <br />1UX0Z- 2 O.3 <br />47•3 <br />CL rv7 C.c+t <br />Pharmaceutical waste <br />RX1 2 { <br />3. Generator's CertIfleatlon: `i hereby declare that the contents of this consignment are fully and accurately TOTALS 10 - <br />described <br />described above by the proper shipping name, and are classified, packaged, marked and labelted/plecarded, and <br />are in all respects in proper condition for transpon a000rdhg to applicable international and national govern ntal regulatil <br />]i :`�._._.,.__, ..--- r�..,, rte► � .... /i •- __ � <br />°� <br />4. TRANSPORTER I ADDIJESS: - <br />Sterlcycle, Inc. Titin is a Through Shipment <br />Phone4. <br />Sterityr3e Inc -AutDdave <br />We -Rt. Swift. Ave. <br />`aulePr°fi�'eg`'�100 <br />a4135 <br />a• <br />Fresno,ca 93722 <br />fd=rlbad <br />ems Q <br />TRANSPORTER CERTIFICATION: Receipt of medical wast as above. <br />TS/OST22 <br />~ <br />Printflype Name -- - �4AR I� . Te Y' :* Signature <br />SJ a1 <br />Date G ' <br />TREATMENT FACILITY: ice <br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Phone k: <br />N <br />PrsMJType Name <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />j <br />z <br />t <br />t <br />PrinVrype Name Signature <br />19 <br />Date <br />n <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Pie q; <br />W <br />Applicable Permit Numbers: f <br />S a c <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste a$ described above. <br />I <br />RL <br />P intrrypo Name Signature <br />Dale <br />?.DISCREPANCY INDICATION " ��fifffvd 2 ttl <br />t�aUeis, , dl A to ; North Salt Lake. ui <br />100201 <br />as. Alternate Facility: <br />Stedcyde Ino- Indnerdon <br />90 NORTH t 100 WEST <br />NORM SALT LAKE CITY, UT <br />(80 1) 936 - 1585 <br />3A -448 -JA -36 <br />$C, Attemate Facility. <br />SterIcyde IRC-Autodave <br />1345 DootiBte Drive Ste C <br />San Leandro, CA 94577 <br />($10) 562.2197 <br />TS311TS1OS'T25 <br />8%9fc�e fn1c'%i clove <br />2775 E 26T}i STREET <br />VERNON, CA 10023 <br />(3231362- 3000 <br />TStOST-26 <br />rtRti Aft �y the applicable state agency to accept untreated medical wastes and that I have <br />wastes in accordance with the requirement outlined in that authorization. <br />tptRfefta'fSt?SlAd 12•htayr.7.ftI4 <br />Date <br />BA, Daalgnefed Fak:ttlty: <br />Sterityr3e Inc -AutDdave <br />4135 W. SWIFT AVE <br />FP•ESNO,CA 93722 <br />(559) 275 - 1121 <br />TS/OST22 <br />Q <br />DALE ". <br />'tdd�Cvt1WED <br />W <br />TREATMENT FACILITY: ice <br />F # <br />received the agave indicated <br />PrsMJType Name <br />100201 <br />as. Alternate Facility: <br />Stedcyde Ino- Indnerdon <br />90 NORTH t 100 WEST <br />NORM SALT LAKE CITY, UT <br />(80 1) 936 - 1585 <br />3A -448 -JA -36 <br />$C, Attemate Facility. <br />SterIcyde IRC-Autodave <br />1345 DootiBte Drive Ste C <br />San Leandro, CA 94577 <br />($10) 562.2197 <br />TS311TS1OS'T25 <br />8%9fc�e fn1c'%i clove <br />2775 E 26T}i STREET <br />VERNON, CA 10023 <br />(3231362- 3000 <br />TStOST-26 <br />rtRti Aft �y the applicable state agency to accept untreated medical wastes and that I have <br />wastes in accordance with the requirement outlined in that authorization. <br />tptRfefta'fSt?SlAd 12•htayr.7.ftI4 <br />Date <br />