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07/05/2011 TUE 10:20 FAX 0002/013 wMEDICAL WASTE TRACKING FORM NUMBER ®® ®® Stiericycle• in CASE OF EMERGENCY CONTACT: CHEMTREC 9.8004124-9300 STANDARD MAWFEST 001.104e•STD ft PW*. , - Route #: 301 - 12 CUSTOMER No. 21132 MDFROOBZMZ L- _--_-- -- -- -- .- tpttTtetrartSEl521iLd 234+►2iif1 1. Generator's Name, Address and Telephone Number ATTN: Mike Campos WAGNER BEIGM NURSING l 9289 BRANSTST'ITiR PL TOMABILITATION S'!l'X-"ICIbNs C?+ 95249- 1700 I (209) 474-4569 6/27/2011 CusTO EA NutsM 6020465-002 GENMATOR•e REOSTRATM a 2A. DESCRIPTION OF WASTE 29. CONTAINERTYPE 2C. NO. OF 2D. VOLUME UN3291, Regulated Medical Waste, rl&s., 6.2.PGII YH57 - 90 Gal Tub {bio) ( cu ft) CONTAINERS Cn FL UN3291, Regulated Medical Waste, n,o.s., 6$ PGO TH49 - 37 Gal Ship (bio) (4. 9 cu tt) Cu Ft. M &.2,PGIi Reglt ed Mewl Waste.n os., ?814 - 34 Gal Tub (Bio) (5.9 cu Yt) 5. p� Cu Ft. != ,Q UN3291. Regulated Medical Wane, e.os., TB21 - 20 Gal Tub (Bio) (2.7 cu ft) cc 6.2, PGII Cu Ft, W Z UN3291, Regulated Medical Waste, n.os., 6.2, PGO 7815 - 20 Gal Tub (Path) {2.7 CU ft) Cu Ft. 623911�RegulatedMedicalWaste,n.O.s., 7Y15 - 20 eel Sub (Chemo) (2.7 cu ft) I Cu Ft. UN3291 Regulated Medical Waste. n.os., 6.2, PGIi Cu Ft. UN3291, Regulated Medical waste, e.os., 6.2. PGO u Ft. Pharmaceutical Waste Ft. 3. Generator's Certification: -1 hereby declare that the contents of this consignment are fully and accurately TOTALS 10,( 1 C' J Cu Ft. described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and are in all respects in proper�nclidon for transport according to applicable international and national govern Mal regulations' Ix_ i Ott 1/l1��f / ! �J� + g yi, `6 Printedrryped Name VSignatureA Oata Ix 4. TRANSPORTER t ADDRESS: hon":J -D y F Stericycle, Inc.is is a h 1. Applicable Permit Numbers: 4%0 4135 Rest Swift Ave. hauler Reg# 3400 2 a Fresno,Ca 93722 Z TRANSPORTER CERTIFICATION:of medical waste as described . ~ Receipt PAnt/rype Name ' ` LA IICi Yr 7 [t/YYDI. Signature Date �/�1 S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone q: 15 Applicable Permit Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print type Name Signature Dais 6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone 8: Applicable Permit Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recsipt of medical waste as described above. � a PdnVType Name Signature Date 7. DISCREPANCY INDICATION Transferred containers, cu A to : Noah Saft Lake, UT 8A. Designated Facility: 68, Atien,ate Facility: u BC. Alternate Facility: 0 BD, Afternale Fetidly: Sierlcyde ltic-Autor1lsve Starlaide iruo- Indneratton Static to Inc-Athodave Inc -Autodm STREET v 4135 W. SWFT AVE SO NORTH t 100 1345 400881e Dr" SO C 277b 26TH L FRESNO,CA 93722 NORTH SALT LAKE CITY, UT San Leandro, CA 54577 VERNON, CA 80023 (559) 275 - 1121 (801) 936. 1555 (5 t 0) 582.2177 (323} 362 - 3444 LU TS/OST22 3A -449 -JA -36 TS31/TS/0ST25 TSIOST 26 a- W - . _. , TREATMENT•FACtLiTY: I certify that) have been authorized by the applicable state agency to accept untreated medical wastes and that I have received the above indicated wastes In accordance with the requirement outlined in that authorization. Prinf/T'ype Name Ilk, P7 2011 Signature Data L- _--_-- -- -- -- .- tpttTtetrartSEl521iLd 234+►2iif1