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07/05/2011 TUE 10:24 FAX 0013/013
<br />• ®qW MEDICAL WASTE TRACKING FORM NUMBER
<br />®® Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.00.424-9300 STANDAR) MANIFEST Dos-taos.STD
<br />Route 0: 301 - 13 Customer: No. 21132 MDFROOA2IP
<br />1. Generator's Name, Address and Telephone Number � � IBM
<br />ATTN: Mike Campos
<br />NAGNER HEIGHTS NURSING 111111 11 1111 [[ till
<br />9289 BRA'NSTETI'ER PL RrsMBILITATION CENM
<br />STOCKTON, CA 95209- 1700
<br />(209) 474-0569 10/25/201(
<br />UN3291, Regulated Medical Waste, n.o s.
<br />6.2, PGII
<br />Pharmaceutical Waste
<br />3. Generator's Certification: 'i hereby dedare that the contents of this consignment are fully and accurately
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled1placarded,
<br />are In all respects in proper condition for transport according to applicable international and national govemrr
<br />Printed/Typed Name :5.1- � Signature .
<br />4. TRANSPORTER 1 ADDRESS:
<br />uu Stericycle, Inc.
<br />4135 Test Swift Ave.
<br />g N Fresno,Ca 93722 in 16 a of
<br />c TRANSPORTER CERTIFICATION:
<br />CERTIFICATION: Receipt of medical waste as described above.
<br />~ Print/Type Name "ter G A -?LLYm Signature
<br />5 INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS'
<br />shipment
<br />j INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrintRype Name Signature
<br />i9 v. ,!� � Gt51Y.GY.n, G nn..yLcn J ! 1 n/a,YJr VnI cn J MVunC J.��
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of modical waste as described above.
<br />�r Prinill'ype Name Signator®
<br />7.OISCREPANCY
<br />t
<br />2C. NO. OF
<br />CONTAINERS
<br />VOLUME
<br />RM
<br />l
<br />— Date t t
<br />Phone a: s
<br />Applicable Permit Numbers:
<br />Date _ ! 2S' `t
<br />Phone N:
<br />Applicable Permit Numbers:
<br />Date
<br />Phone s:
<br />Applicable Permit Numbers:
<br />Date
<br />Thonsfm rod cultalnsm, ou R to : North Soft Lake. UT
<br />DesignatedFacility:
<br />CUSTOMER NUMBER 6020465-002
<br />GeNERATOR'SREGISTRATION III
<br />so. Attarnate facility:
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINER TYPE
<br />UN3291, Regulated Medical Waste,n.o.s.,
<br />6.2, PGII
<br />T057 - 90 Gal Tub (Bio) (12 au ft)
<br />90 NORTH 1 IW Y1tEST
<br />UN32911, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />T049 - 37 Gal Tub (Bio) (4. 9 Gu ft)
<br />W
<br />Regulated Medical Waste, n.o.s.,
<br />TS14 - 44 Gal Tub (Bio) (5. 9 Cu 4t)
<br />VERNON, CA 90023
<br />6UN322991,
<br />. PGII
<br />(Sol) ME - t555
<br />!UN3291,
<br />Regulated Medical Waste, n.o.s.,
<br />- a u 10 u
<br />CC
<br />6.2, PGII
<br />02 P-6, P-1 t6
<br />W
<br />UN3291, Regulated Medical Waste. n.o.s.,
<br />T815 - 20 Gal Tub (Path) 02—.7 cu ft)
<br />W
<br />6.2, PGII
<br />UN3291Regulated Medical Waste, n.o.s..
<br />6.2, PGII
<br />TY15 - 20 Gal Tub (Ghemta) (2.7 cu ft)
<br />UN3291, Regulated Medical Waste, n.o.s..
<br />UN3291, Regulated Medical Waste, n.o s.
<br />6.2, PGII
<br />Pharmaceutical Waste
<br />3. Generator's Certification: 'i hereby dedare that the contents of this consignment are fully and accurately
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled1placarded,
<br />are In all respects in proper condition for transport according to applicable international and national govemrr
<br />Printed/Typed Name :5.1- � Signature .
<br />4. TRANSPORTER 1 ADDRESS:
<br />uu Stericycle, Inc.
<br />4135 Test Swift Ave.
<br />g N Fresno,Ca 93722 in 16 a of
<br />c TRANSPORTER CERTIFICATION:
<br />CERTIFICATION: Receipt of medical waste as described above.
<br />~ Print/Type Name "ter G A -?LLYm Signature
<br />5 INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS'
<br />shipment
<br />j INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrintRype Name Signature
<br />i9 v. ,!� � Gt51Y.GY.n, G nn..yLcn J ! 1 n/a,YJr VnI cn J MVunC J.��
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of modical waste as described above.
<br />�r Prinill'ype Name Signator®
<br />7.OISCREPANCY
<br />t
<br />2C. NO. OF
<br />CONTAINERS
<br />VOLUME
<br />RM
<br />l
<br />— Date t t
<br />Phone a: s
<br />Applicable Permit Numbers:
<br />Date _ ! 2S' `t
<br />Phone N:
<br />Applicable Permit Numbers:
<br />Date
<br />Phone s:
<br />Applicable Permit Numbers:
<br />Date
<br />Thonsfm rod cultalnsm, ou R to : North Soft Lake. UT
<br />DesignatedFacility:
<br />F88. Anemate Faculty:
<br />BC• Alternate Faculty
<br />so. Attarnate facility:
<br />dcide Inc
<br />35 A�VdEm
<br />'Alltod rve
<br />4 W. SWFT
<br />90 NORTH 1 IW Y1tEST
<br />1346 DDcoMe D Ste C
<br />2775 E 26THMT
<br />FRESN®,CA 93722
<br />NORTH SALT LAKE CITY, UT
<br />San Leandro, CA 94577
<br />VERNON, CA 90023
<br />(559) 275 - CM
<br />(Sol) ME - t555
<br />(510) SS2 - 1781
<br />(323) 362 - 3000
<br />TS31, TS/OST25
<br />TSIOST22
<br />Crass V Incinerabon Perrr& 91
<br />02 P-6, P-1 t6
<br />�
<br />TREATMENT FACILITY: I certity that i have been authorized by the applicable state
<br />H received the above Inds w t s in accordance with the requirement outiloolihn 1
<br />PrinVType Name j5444r4z Signature
<br />o ti
<br />ORIGINAL
<br />accept untreated medical wastes and that 1 have
<br />Ization. O C T 2 5 20 10
<br />�,�_ Date
<br />
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