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07/05/2011 TUE 10:20 FAX 0004/013 <br />• ^-- —�� EDICAL WASTE TRACKING FORM NUMBER <br />• ®tt► Stericycle' IN CASE OF EMERGENCY CONTACT: CNEMTREC 1.80D•424 = STANDARD MANIFEST 001.10.MSM <br />d'a6g10d ve-alfa 4! 301 — 10 CUSTOMER NO. 21132 Mi)FRnnAYi.F <br />i 349 (,! <br />a <br />i <br />1. Generator's Name, Address and Telephone Number <br />ATTN: Mike Campos <br />WAGNERaElGErs NURSING <br />9289 BRANS79TPL RRMILITATION-CEYM�? <br />11 <br />S70CR•MN, CA 95209- 1700 <br />(209) 474-0569 <br />CUSTOMEA NUMBER 6020465-002 Gr-memToA'sRttcrsmmm a <br />, <br />2A. DESCRIPTION OF WASTE <br />29. CONTAINER TYPE <br />2C. NO. OF <br />20, VOLUME <br />UN3291, Regulated Medical Waste, 8.0.5..CONTAINERS <br />62, PGII <br />ct) <br />TW7 - 90 tial Tub (viol (Cu. t <br />Cu FL <br />UN329i, Regulated Medical waste, n.o,s., <br />62, PGU <br />T049 - 37 Gal Tub (Bio) (4.9 Cu ttl <br />Cu Ft. <br />Q6.23291. <br />Regulated Medial Waste, n.o.s.. <br />T014 - 44 Gil Tub (ilia) (S. 9 cu tt) <br />I <br />5. <br />Cu Ft. <br />C <br />UN329i, Aegutated Medical Waste, o.o.s., <br />T82 L — 20 Sal Tub (Vii Cu ftl <br />a <br />62, PGII <br />Cu FI: <br />ti! <br />Z <br />UN3291, <br />6.2. PGI: Regulated Medical Waste, n.o.s., <br />TB15 - 20 Gal Tub (path) (2,7 Cu ft) <br />Uj <br />Cu Ft. <br />623PfIiAeputatedMedicalWaste,n.o.s., <br />7YIS - 20 Gal Tub (Chemo) 42.7 cu ft) <br />Cu FI. <br />UN3201. Regutated Medfcat Waste, n.0 s., <br />6.2. PGII <br />Cu Ft. <br />6 23 �" Regulated Medical Waste, n o s., <br />RX 0 9 - 2 a 1 C p 9_/ <br />rP�t <br />2 <br />0,-3 <br />a <br />+ u FL <br />Pharmaceutical Waste <br />Rx l 2 - [ 2 a <br />312- <br />C. Fl, <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are luffy and accurately TOTALSP- <br />4 t Cu Ft, 1 <br />described above by the propershipping name, and are classified, packaged, marked and iabelled/placarded, and I <br />are in all respects In proper condition for transport rdstg to applicable international and national governmental regufstfon <br />i_i <br />.Printed/typed Name �-- Signature is 4Date <br />N <br />4. TRANSPORTER t ADDRESS: <br />Phone 8: - <br />'. <br />Stericycle, Inc. Shipment <br />Applicable Permit Numbers: <br />CO <br />4135 bast Swift Ave. <br />Hauler Reign 3400 <br />a <br />Frestib, Ca 93122 <br />a Q <br />Laough <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as scribed a <br />i <br />~ <br />PrinVlype Name �'Q�'1-� Y • � 7' Signature <br />Date 3 f M <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone M <br />erg, <br />Applicable Permit Numbers: <br />� c <br />111 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrUfflype Name Signature <br />Date <br />e, INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: <br />Phone ff: <br />Applicable Permit Numbers: <br />S z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt medical <br />lwz <br />of waste as described above. <br />S <br />PrinVRype Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />3 3 5 <br />Tri e Coen r$• Ise 1: to :Kann Sae Lake, UT <br />8A.Oesfgnsted Facility: a9. Alternate Faculty: OC. Alternate Foollity: <br />El BD. Aitamate Facility: <br />8beftde Inc-Auli)dave SlINICYde Ina I )itt:-A <br />1345 DtMe Sir• C <br />inG-A <br />2715 26TH STRE97: <br />v <br />4133 W. SWIFT AVE 30 N i t OD <br />U. <br />FRESNO.CA 23M2 NORTH SALT LAKE CITY, UT Satz Leandro, CA 94577 <br />VERNON, CA 90023 <br />zz <br />(M) 275 - 1121 (Sot) 235 - 1 Sbi (M) 90 - 2177 <br />(3231382.3000 <br />W <br />TSIOST22 -36 TS311i:StOS'"M <br />TS(= -28 <br />WILSON <br />w <br />�j� A��p�C <br />TSQATNtE FACiLITYcertify that i have been authorized by the applicable state agency to accept untreated <br />medical wastes and that I have <br />I— <br />received the above Indicated wast a cgld evith the requirement outlined in that authorization. <br />Prindrype Namk dV 11 1 2011 V NN UU 1 Signature <br />Date <br />i 349 (,! <br />a <br />i <br />