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07/05/2011 TUE 10:23 FAX 2010/013
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />j
<br />0.-.06 Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800424-901W STANDARD ► ANWESY 0001-100e•STO
<br />( "°°°'"fto°.'`",tw Route J: 301 - 12 Cur tomwElIlao.22t132 MDFRDOAF6C
<br />I 1. Generator's Name, Address and Telephone Number €€ i
<br />� ATTId: Mabe Campos
<br />GHER BEIGB'I5 NURSI
<br />9289 MISTETTER PL RBBABILITATION CETM
<br />S7X)CKKMW, CA 95209- 1700
<br />(209) 474-0569 1/11/2013
<br />t
<br />UN3291. Regulated Medical Waste, n.o.s..
<br />UN3291Regulated Medical Waste, n.o.s.
<br />6.2, PGli
<br />marmaceutical (daste
<br />3. Generator's Certification: 9 hereby declare that the contents of this consignment are fully and accurately TOTALS P.
<br />described above by the proper shipping name, and are classified, packaged, markw and Iabelted/placarded, and
<br />are intt all respects in proper condition for transport according to applicable international and national governmental r gubl ns.-
<br />I IPrinted/ryped Name e i:u Y" � -- A w iLL� Signature
<br />2C. NO. OF 2D.
<br />CONTAINERS
<br />VOLUME
<br />11t.711f
<br />d. TRANSPORTER 1 ADDRESS: Phone N: (55 9) U_D
<br />w Stericycle, Inc.
<br />a � 4135 West Swift Ave. Applicable Permit Numbers:
<br />< � ': =esno, Ca 9:6722 is ht: gh Shipment
<br />a q TRANSPORTER CERTIFICATION: Receipt of medical waste as described.
<br />cc
<br />Print/rype Name d V. T Signature Data I t
<br />S. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone A:
<br />gApplicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />i&r
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone C
<br />c Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Typo Name Signature Date
<br />I 7. DISCREPANCY INDICATION
<br />8A, Oealgneked Faculty:
<br />Stsricyde Inc-Autodave
<br />4135 W. SWIFT AVE
<br />FRESNO•CA 93722
<br />(559) 275 - 0994
<br />TS31, TS1OST25
<br />Transferred Containers, Cu R to: North San lake, UT
<br />1B. Alterru to Facility:
<br />Sbaricycle Ino- Incineration
<br />90 NORTH 110t)V4 ST
<br />NORTH SALT LAKE CITY, LIT
<br />(801) 939. 1555
<br />TSIOST22
<br />DC, Alternate Facility:
<br />Sb dcysde Inc -Autodave
<br />1345 DoCttthe Drtve Ste C
<br />San Leandro, CA 54577
<br />(5411)562- 1781
<br />Class V Indneratton Petmli# 91
<br />80. Alternate Facility:
<br />Stericyde Inc -AUIDdave
<br />2775 E 26TH STREET
<br />VERNON, CA 90023
<br />(3231352.3000
<br />P6,P-I t5
<br />TREAT Certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received Hca ed wastes in accordance with the requirement outlined in that authorization.
<br />�1 its ��iss�i
<br />Signature
<br />tptt3oibr QYtd 14 Jar►2Qi! tJt° lUIN L
<br />Date
<br />CUSMUER NUMBER 6020465-002
<br />GEXaAMirsft rsTR Tm0
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINER TYPE
<br />UN3291, Regulated Medial Wada, n.o.s.,
<br />6.2, PGIi
<br />TE571 - 90 Gal Tub (Bio) (12 Cu tt)
<br />UN3291,Regulated Medical Waste. n.o.s.,
<br />T849 - 37 Gal Tub (Bio) (4.9 Cu tt)
<br />6.2, PGII
<br />M
<br />Regulated Medical Waste, n.o.s.,
<br />TB14 - 44 Gal Tub (Bio) (S. 9 cu tt)
<br />6UN23�t,
<br />C
<br />UN3291. Regulated Medical Waste, n.os..
<br />- Cie M cu
<br />a
<br />6.2, PGII
<br />W
<br />UN3291,Regulated Medical Wage. ao.s.,
<br />T815 - 20 Gal Tub (Path) (2.7 cu tt)
<br />Z
<br />6.2. poll
<br />82329, Regulated Medial Waste,n.os.,
<br />7715 - 20 Qat Tub (Chemo) (2.7 cu tt)
<br />UN3291. Regulated Medical Waste, n.o.s..
<br />UN3291Regulated Medical Waste, n.o.s.
<br />6.2, PGli
<br />marmaceutical (daste
<br />3. Generator's Certification: 9 hereby declare that the contents of this consignment are fully and accurately TOTALS P.
<br />described above by the proper shipping name, and are classified, packaged, markw and Iabelted/placarded, and
<br />are intt all respects in proper condition for transport according to applicable international and national governmental r gubl ns.-
<br />I IPrinted/ryped Name e i:u Y" � -- A w iLL� Signature
<br />2C. NO. OF 2D.
<br />CONTAINERS
<br />VOLUME
<br />11t.711f
<br />d. TRANSPORTER 1 ADDRESS: Phone N: (55 9) U_D
<br />w Stericycle, Inc.
<br />a � 4135 West Swift Ave. Applicable Permit Numbers:
<br />< � ': =esno, Ca 9:6722 is ht: gh Shipment
<br />a q TRANSPORTER CERTIFICATION: Receipt of medical waste as described.
<br />cc
<br />Print/rype Name d V. T Signature Data I t
<br />S. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone A:
<br />gApplicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />i&r
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone C
<br />c Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Typo Name Signature Date
<br />I 7. DISCREPANCY INDICATION
<br />8A, Oealgneked Faculty:
<br />Stsricyde Inc-Autodave
<br />4135 W. SWIFT AVE
<br />FRESNO•CA 93722
<br />(559) 275 - 0994
<br />TS31, TS1OST25
<br />Transferred Containers, Cu R to: North San lake, UT
<br />1B. Alterru to Facility:
<br />Sbaricycle Ino- Incineration
<br />90 NORTH 110t)V4 ST
<br />NORTH SALT LAKE CITY, LIT
<br />(801) 939. 1555
<br />TSIOST22
<br />DC, Alternate Facility:
<br />Sb dcysde Inc -Autodave
<br />1345 DoCttthe Drtve Ste C
<br />San Leandro, CA 54577
<br />(5411)562- 1781
<br />Class V Indneratton Petmli# 91
<br />80. Alternate Facility:
<br />Stericyde Inc -AUIDdave
<br />2775 E 26TH STREET
<br />VERNON, CA 90023
<br />(3231352.3000
<br />P6,P-I t5
<br />TREAT Certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received Hca ed wastes in accordance with the requirement outlined in that authorization.
<br />�1 its ��iss�i
<br />Signature
<br />tptt3oibr QYtd 14 Jar►2Qi! tJt° lUIN L
<br />Date
<br />
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