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07/05/2011 TUE 10:20 FAX ti ®® Stericycle' a tw+.aweoaal: IN CASE OF EMERGENCY CONTACT: CHEMTREC 14100,4244m In—4— A. 't A i 14 CUSTOMER NO. 21132 1. Generator's Name, Address and Telephone Number ATTN: Mike Campos WAGNER fg'ICiM NURSING 9289 BRAIyS'IiSrM PL REEiA►SI,LITATIO'd CEVMR STOCK'P)7t, CA 95209- 1700 Cumaren NUMBERR Gt:v Tnw^a ttvnr"UAT a 2003/013 MEDICAL WASTE TflPICKING FORM NUMBER STANWNO MANIFEST 001.10,WSt0 MDFROOBOCS 6/13/2011 2A_ DESCRIPTION OF WASTE 107 CONTAINERTYPE 2C. NO.OF 20. VOLUME UN3291, Regulated Medical Waste, n.o.s., A. Designated Facility CONTAINERS &C. Alternate Facility: aD. Altemata Facility: 6.2, PGII _ L SterIcycle Incineration Cu FL UN3291, Regulated Medical Waste, LL 4135 W, SWIFT AVE 90 NORTH 1100 WEST 6.2. PGII TB99 - 37 I^,a1 Tub (Bio) (4. 9 cu ft) H Cu Ft. UN3291. Regulated Medical Waste. n.o.s., Sen Learifro, CA 34577 VERNON, CA 90023 dt 6.2 PGII TB1 - 44 Gal Tub (Bio) (S. 9 cu ft) (510) 562- 2177 Jf"" f Cu FL UN3291Regulated Medical Waste, n.o.s., �. Tsstrrslosrts 62. PGti TB21 - 20 Gal Tub (Bio) (2. 7 cu ft) D LA AN C) T1 I Cu Ft. UN3291, Regulated Medial Waste, n o.s. received the above indicated wastes in accordance with the requirement outlined in that authorization. 6.2, PGII TB15 - 20 Gal Tub (Path) (2.7 Cu ft) Cu Ft. UN3291, Regulated Medial Waste, n.os., Signature 6.2. P611al Tub Chemo 2.7 Cu ft) Cu Ft. UN3291, Reguiated Medical Waste, n.os., 6.2. PGI! Cu Ft. UN3291, Regulated Medical Waste, n&s., 6.2. PGII Cu Ft. pile W808 0 Cy F. 3. Generator's Certification: 'I hereby declare that the contents of this consignment are fully and accurately TOTALS ® } S - Cu Ft. descri2led ahnve by the nuxurt ahinrdnn namn anA ara MAtedI&A tm.*e d manda nnA InhannAlniewnM, e_a are in all respects in proper condition for transport according to applicable international and national governmental Printedrtyped Name IIUW r Signature I " Is a 13 /f 4. TRANSPORTER t ADDRESS: Phone e; � (559)275-1121 Stericycle, Inc. 0 Th is is a ou Shipment Applicable Permit Numbers: 2 a 4135 :test Swift Ave. Hauler Reg# 3400 `Fresno Ca 93 722 a d TRANSPORTER CERT)FIdkf1ON: Receipt of medical waste as described above. cc I Print/Type Name �'e X PA97-e . Signature Date�3 d8 5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone N: Applicable Permit Numbers: QW$ l z = INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: R ipt of medical waste as described above. Prinittype Name Signature Date 5. IN I t:HMtU4AI E MANULEM 31 TRANSPURTER 3 ADDRESS: Phone #: 3 w Applicable Permit Numbers: a INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as desuibed above. z x - Print/Type Name Signature Data 7. DISCREPANCY INDICATION Transferred cotnainers, col It to : Worth Salt Lake, UT A. Designated Facility 08. Alternate Facility: &C. Alternate Facility: aD. Altemata Facility: (j $ierlC}/d8 Inc-AtttOdt9Ye SterIcycle Incineration SterlCYde IflC-AtItOLIaVB Sia de Inc -Autodave LL 4135 W, SWIFT AVE 90 NORTH 1100 WEST 1345 0tfW# DPW# Ste C 2775 2M STREET H FRESNO,CA 93722 NORTH SALT LAKE CITY, UT Sen Learifro, CA 34577 VERNON, CA 90023 (559) 275 - 1121 (801) 936. 1566 (510) 562- 2177 (323) 362 - MOD �. Tsstrrslosrts Tsrc�sT-2f3 D LA AN C) T1 I TR A NT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have H received the above indicated wastes in accordance with the requirement outlined in that authorization. Printrrype Nar,41N 18 2011 Signature Date