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07/05/2011 TUE 10:23 FAX 0011/013
<br />`e+• ------------ ---_..r.._-__._�--.�---..--, - ___. � . _ MEDICAL WASTE TRACKING FORM NUMBER
<br />i® ®i Stericytle, 1N CASE OF EMERGENCY CONTACT: CHEMTREC 1-800424.9300 STANDARD MANIFEST 001.1 -06-STO
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<br />75-..4-.. Jf. 4f11 - 1 1 niC11.STnfAEANO..d4M
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<br />1. Generator's Name, Address and Telephone Number
<br />AWN: Mire Campos I I I i1 1111111111 oIII
<br />WASHER EEIMTS NURSING
<br />9269 BRANST!sZ`1'ER PL RFBABILITATION CEWER
<br />STOCE'l V, CA 95209- 1700
<br />{209) 474-0569 1/10/2011
<br />CusTOMER NumeER 6020465-002 EWERATosrs REctsyrtAnoNN
<br />2A. DESCRIPTION OF WASTE 2a. CONTAINER TYPE
<br />2C. NO. OF 2D, VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />CONTAINERS
<br />6.2, PGII TD57 - 90 Gal Tub (Dio) (12 Cu tt)
<br />Cu Ft
<br />Regulated Medical Waste, n.o.s.,
<br />2.
<br />6 PGII T049 - 37 Gal Tub (Rio) (4 . 9 cu it)
<br />Cu Ft.
<br />m
<br />p
<br />UN3291, Regulated Medical Waste, mo.s.,
<br />6.2, PGII T514 - 44 Gal Tub (Dia) (5.9 Cu tt)
<br />q
<br />5
<br />• i Cu Ft.
<br />aUN3291,
<br />Regulated Medical waste, n.os„ TB21 - 2Q tial Tuts (Bio) (2.7 cu ft)
<br />6.2. PGII
<br />UJI
<br />UN329t, Regulated Medical Waste, n.os.,
<br />Cu Ft.
<br />Z
<br />6.2, PGII T015 - 20 Gal Tub (Pahl) (2. 7 cu tt)
<br />W
<br />Cu Ft.
<br />UN3291Regulated Medical Waste, n.os.,
<br />6.2, PGII TY15 - 20 Gal Tub (Chemo) (2.7 au tt)
<br />Cu Ff.
<br />UN3291, Regulated Medical Waste, mos.,
<br />6.2, PGII
<br />u Ft.
<br />U143291, Regulated Medical Waste, mos.,
<br />6.2, PGII
<br />Cu ft,
<br />Ft.
<br />3, Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurate TOTALS ® Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelied/piacarded, and --
<br />are In all respects in proper condition for transport according to applicable International and national governments r gulations"
<br />Prime ed Name i O
<br />dlTyp Signature Date
<br />4. TRANSPORTER 1 ADDRESS: Phone a: (559) 275 - o
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<br />Sterieycle, Inc . Applicable Permit Numbers:
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<br />4135 t Swift Ave.
<br />in a coag Shipment:
<br />v,
<br />Fresno,Ca 93722
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<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />~
<br />PrtnVrype Name — Ly. / 4en `A. Signature Date % �l
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone q;
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />Print/type Name Signature Date
<br />e`t
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRE$S: Phone 0:
<br />n
<br />0
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt o1 medical waste as described above.
<br />Pfinifrype Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />T maternd caffthwn, eI A to: North Salt Lake UT
<br />GA, Designated Facility: 66. Alternate Facility: ® aC. Afternate Facility; U 80. Alternate Factlity:
<br />StaAcycle Inc Aubxtm [no.1 IncAu!>odm trlc-Atiibo M
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<br />4136 W, SV;AFf AVE 90 NORTH t tt)D 1345 0011116 DrNs Sts C 2775 26TH STREET
<br />FRESNO.CA 93722 NORTH SALT LAKE CITY. UT Sart t.snndfv, CA 94577 VERNON. CA 90023
<br />(559) 275 - 0994 (1101) 9316. 1555 (510) 562 -1761 (323 362 - 3=
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<br />TS3 1. TSlOST26 TSIOST22 V 1 Perrri 91 t 6, P-1 is
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<br />ANNE
<br />AUTOCLVED Z
<br />TREATMENT FACILITY: 1 certify that I have been authorized by the applicable state
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<br />a-
<br />agency to accept untreated medical wastes and that 1 have
<br />received thajba4ejn5jc?L5Pjwastes in accordance with the requirement outlined in that authorization.
<br />Print/Toe Name Signature Date
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