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07/05/2011 TUE 10:24 FAX <br />0012/013 <br />-MEDICAL WASTE TRACKING FORM <br />i `®:Sterieyete' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-42"3D0 <br />®® <br />Nt/MBEp <br />STANDARD MANIFEST 001•10-0e-STD <br />Route #: 301 - 13 Customer No. 21132 <br />MDFROOAAVJ <br />I. Generator's Name, Address and Telephone Number <br />{ <br />ATTN: Mike Pus l <br />ii tt <br />WAGNER IMIGHTS URSING <br />2899 A-dSTETTEtiEtiR 7'L RABILITATION CB • <br />9B <br />STOC•RTON, CA 95209- 1700 <br />(209) 474-0569 <br />12/20/201( <br />1 <br />CusTouERNUMBER 6020465-002 GENERATOR'S REGISTRATION M <br />I <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINER-TYPE <br />2C. NO.OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />T857 - 90 real Tub (Bio) (12 Cu ft) <br />CONTAINERS <br />UN3291, Regulated Medical Waste, n.o.s.. <br />TB49 - 37 Gal Tub (Bio) (4.9 cu ft) <br />Cu FI. <br />6.2, PGII <br />CC <br />UN3291, ReguWted Medical Waste, n.o.s., TB14 - 44 Gal Tub (Rio) (5, 9 Cu ft) <br />Cu Ft. <br />t7 <br />6.2, PGfl <br />Q <br />- <br />Medical Waste, n.o.s.. TB Ga Bio Cu <br />Cu Fl <br />i <br />60232" Regulated <br />W <br />UN3291, Regulated Medical Waste, n.os., TB1S - 20 Gal Tub (Path) (2 _ 7 cu tt) <br />Cu Ft. <br />+ <br />I Z <br />6.2, PGII <br />j <br />UN3291, Regulated Medical Waste, n.os., TY15- 20 Gal Tub (Chemo) (2.7 cu ft) <br />fit, PGII <br />Cu Ft, <br />UN3291, ReguWted Medical Waste, n.o.s., <br />Cu Ft. <br />I <br />6.2. PGII <br />I <br />UN3291, Regulated Medical Waste, <br />Cv Ft. <br />6.2, PGII <br />Cu Ft. <br />Pharmaceutical waste <br />F <br />3. Generator's Certification: 9 hereby declare that the contents of this consignment are fully and accurately T®TAL$ ® <br />QCu <br />described above by the proper shipping name, and are classified, packaged• marked and labelled/ plaoardek;, and <br />Ft. <br />are in all respells in proper condition for transport aoeordi�pplicable international and national governmeptatfegulations" <br />1rnnlecvT ped Name SignatureOate <br />4. TRANSPORTER t ADDRESS: <br />Stericycle, Inc. <br />f� <br />Phone M: <br />sZ <br />y <br /><cr <br />9335 Rest Swift Ave. <br />Applicable Permit Numbers; <br />i eco <br />1 g y <br />is a tough hipment <br />Fresno, Ca 93722 <br />a < <br />TRANSPORTER CERTIFICITION: Receipt o1 medical waste as described above. <br />{� rx <br />~ <br />'ti '�- <br />�� <br />I <br />Print/Type Nanta lt/�+ r Signature DateZ' `o <br />6. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone 0: <br />r <br />,r <br />Applicable Permit Numbers: i <br />11 <br />1 �x <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />, <br />PrinVt"ype Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone M: fI <br />o <br />Applicable Permit Numbers: <br />S a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />7. DISCREPANCY INDICATION <br />pate 1 <br />1 <br />Transferred containers, r.011 to : North Safi lake, UT <br />0 BA, Designated Facility: ❑ a6. Attamdts Facility: BC. Atternme Fac6hy; <br />Sp, Altamata Facility: <br />E <br />Stericyde Inc -AuWave Sbaricydmb <br />e Ina- Indneon a Inc -Autoclave <br />A 135 W. SWIFT AVE 90 NORTH t 100 WEST 1345 DooWe DYW Ste C <br />SWdcyde Inc Rtatodave <br />2775 '2M <br />t v <br />E STReET <br />LL <br />FRESNO,CA 93722 NORTH SALT LAKE CITY, UT San Leandro, CA 94577 <br />VERNOWCA. 90023 i <br />(559) 27S - 0994 (sal) 936 - 1555 (510)1. 62- 1781 <br />(323) 362.3000 i <br />7S31.TS106125 iStOSlI'?2 ClassVlndneratlOnPemti!#9i a2 <br />P-6.P-115 <br />a <br />DALE ANNE ORTI <br />W <br />TREATMENT FACILITY: I certify that i have been authorized by the applicable state agency to accept untreated medical wastes and that I have i <br />received the above indicated wastes in accordance with the requirement outlined in that authorization, <br />l <br />Pfintrrype Name Signature Date <br />//���y �% <br />Q �Llrd.O� <br />� <br />i;fd is-oticme apt <br />l <br />