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9/24/2010 16:40 <br />®® Stericycle' <br />. "Not*9 Pw*. ft*xbv wA. <br />Remote ID Imprint ID <br />OF EMERGENCY CONTACT: CHEMTREC <br />Ttn,.i-® A. :aril - IF, <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001 -10.06 -STD <br />Mnt; RnnA7.PT <br />ORIGINAL <br />4 <br />1. Generator's Name, Address and Telephone Number <br />ATTN: Caroline Jackson <br />WAGNER EEIGHTS NURSING <br />9289 BRA14STETTER PL REHABILITATION CENTER <br />STOCKTON, CA 95209 1700 <br />(209) 974-0562 <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION # <br />' <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINER TYPE <br />2C. NO. OF <br />213. VOLUME <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />CONTAINERS <br />UN 3291, PG 11Cu <br />Ft. <br />REGULATED MEDICAL WASTE, n.o.s.52, <br />UN 3291. PG It <br />TB49 - 37 Gal Tub Elio 4.9 Cu ft <br />_ <br />_ _ Cu Ft.. <br />pC <br />REGULATED MEDICAL WASTE, n.G.s.,6.2. <br />Q <br />UN 3291, PG II <br />TB14 - 44 Gil Tub Bio J5. 9 Cu tt <br />Cu Ft. <br />Q <br />M <br />REGULATED MEDICAL WASTE, n.e.s..6.2. <br />UN 3291, PG II <br />TB21 - 20 Gal Tub (Bio) (2.7 cu ft) <br />Cu FL <br />W <br />REGULATED MEDICAL WASTE, n.e.5.,6.2, <br />UN 3291, PG It <br />TBl - 20 Gal Tub Path 2.7 cu ft <br />Cu Ft. <br />tZ <br />0REGULATED <br />MEDICAL WASTE, n.o.s.,62, <br />UN 3291, PG II <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />UN 3291, PG II <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.o4.,6.2. <br />UN 3291, PG II <br />Cu Ft. <br />Cu Ft. <br />LahamagailvAgaa <br />3. Generator's Certification: "I hereby declare that the contents of this consignment aro fully and accurately TOTALS ® <br />G� <br />! 1 Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regula <br />0X�4 <br />" "8 <br />e <br />PrintedrTyped Name t.ii0 nGt N §nature <br />4. TRANSPORTER 1 ADDRESS: <br />Date <br />Phone #: tt rr,, - 0994 <br />tr <br />LU <br />y. <br />Straricycle, Inc. <br />Applicable PerWdWbk <br />a O <br />Di <br />4135 Rest Swift Ave. <br />This isbThhShipment <br />a <br />Fe�ll o C 93722 <br />TRANSPORTER GMFIbillON: Receipt of medical waste as described above. <br />~ <br />i <br />��� �• �a''Y'r� <br />8 /O <br />Print/Type Name Signature <br />Dale <br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Phone # <br />n�y <br />¢ <br />Applicable Permit Numbers: <br />� <br />pW� <br />0. <br />�EC <br />� <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />r <br />Printrrype Name Signature <br />Date <br />¢ <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone # <br />a ¢ <br />J <br />Applicable Permit Numbers: <br />y0 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of modical waste as described above. <br />Z s <br />Print/type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />• NoMh Salt aka U <br />8A. Designated Facility: 88, Alternate Facility: 0 8C. Alternate Facility: <br />®813. Alternate Facility: <br />STERICYCLE INC STERICYCLE INC STERICYCLE INC <br />STERICYCLE INC <br />Q <br />4135 W. SIM FT AVE 90 NORTH 1100 WEST 9053 NORRIS AVE. <br />2775 E 26TH STREET <br />F <br />FRESNO,CA 93722 NORTH SALT LAKE CITY, UT SUN VALLEY, CA 91352 <br />VERNON. CA 90023 <br />(659) 276 - 0994 (80 1) 936 - 1555 (8 18) 5134.6937 <br />(323)362. 3000 <br />W <br />2- <br />T531, TS/OST25 TSIOST22 Class V I ndneration Permit# 91- 2 P-6, P-11 S <br />W <br />TREATMENT FACILITY: I rti at 1 have been authorized by the applicable to age y�l accept untreated <br />medical wastes and that l have <br />Imo— <br />received the above ' ed sin accordance with the requireme ed in th t ation. <br />FEB 0.9 2010 <br />p <br />Q� �A��`l ��R <br />Prinlrrype Name Signatures = <br />Date <br />ORIGINAL <br />4 <br />