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MEDICAL WASTE TRACKING FORM NUMBER
<br /> ®� Stericyclw IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-00.234.0051 STANDARD MANIFEST 001.10•06•STO
<br /> ®,• rto�tct�gMpM.tM�cigldS: Route #: 413 22
<br /> I - lan)Zr_nn�v*�Er
<br /> t 1,Generator's Name,Address and Telephone Number
<br /> Ann
<br /> ARBOR CANNA ESC NTHOSPITAL � � �
<br /> coo NORTH CHURCH 3TREET
<br /> { L©Dir CA 95240 .
<br /> I (2Q9) 223-1,222 0/28/200S
<br /> CUSTOMER NUMBERr„ �, G&aRaorti REOISTRA'norr
<br /> 0
<br /> 2A.DESCRIPTION OF s 20 w` CONTAINERTYPE 2C.NO.OF 2D. VOLUME
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, CONTAI RS
<br /> UN 3291,PG 11 8 - B a t.h) 44 Oral Job 15.9 cnx ft) Cu FI.
<br /> REGULATED MEDICAL WASTE n.o.s.,6. ,
<br /> UN 3291,PG 11 T021-(Bio) / THIS-(Path / TY15-(Chemo) 20 Ga? Tub (2.7) Cu Ft.
<br /> tE REGULATED MEDICAL WASTE,n.o.s..6.2.
<br /> O UN 3291,PG if TB49-(Pio) / TN43-(Path) / TY49-(Chamo) 27 Gal Tub (4.9) Cu Ft.
<br /> I REGULATED MEDICAL WASTE,n.o.s.,62,
<br /> CC UN 3291,PG 11 TB25 - 26 Gal. Tub (Bic) (3.5 cu ft~) Cu Ft.
<br /> W REGULATED MEDICAL WASTE,nx.s.,62,
<br /> W UN 3291,PG 11 TEST - 90 Gal Tub (Bio) (12 cu ft) Cu Ft.
<br /> 0 REGULATED MEDICAL.WASTE.n.o.s.,6.2,
<br /> UN 3291,PG 11 rpF4a _ Ar r-'21 r,<t In;�% fr n .r «.•1 Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, V ^- 5.1 4 - _
<br /> UN 3291,PG 11 Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, - " """' `"' ' ""
<br /> UN 3291,PG 11 4RI44 NCA r_,1 M-%, rn4„1 ro r? 9..1 Cu Ft_
<br /> I
<br /> Pbarmacelrtical Waste Cu Ft.
<br /> 3.Generator's Certification:"I hereby declare that the contents of this oonsoment are bully and accuratelyT®TALS M' Cu Ft.
<br /> i described above by the proper shipping name,and ara classified,padkagod,marked and tabettedlptacard6d,and
<br /> i are in all respects In proper condition for transport according to applicable international and national govemmental regulations'
<br /> IXVZ e
<br /> lP„�Printed/Typed Name f Signal re Oat.
<br /> A,TRANSPORTER#ADDRESS: Phone 6:
<br /> CC 4, 53S (3
<br /> STERIC'.CL•E Applicable Permit gars:
<br /> a 11875 White Rock Fid
<br /> i `)this i `I`ktI our meet
<br /> v1 Rar:ae.-+ Cordov,a.t:A. 95.+42
<br /> f a z TRANSPORTER CE FIC ON:Receipt of medical waste as descrIb abo
<br /> P(int(Type Name Signature Date
<br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone s:
<br /> a Applicable Permit Numbers:
<br /> In
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as dewlbod above.
<br /> i
<br /> Printflype Name Signaluro Date
<br /> ro 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone q:
<br /> a Applicable Permit Numbers:
<br /> W
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Hr P(Ini/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Tr�ncfarrari rnl�inarc n,R - hlnr h qm%lmttp IT
<br /> 8A.Deslgneted Facility: as.Alternate Fnetaty: U aC,Alternate Facility: 8D.Attonu to Facility;
<br /> T)=RICYrl P Nd(: STERICYCLE,INC. STERICYCI E.INC. 9TERICYCLE,INC.
<br /> 1.145 Doolittle Drive,Suite C 4135 W SlrM Avenue 00 Nomh f 100 W--st I%12 Starr Dr
<br /> is San Le3ndTo,CA 94577 Fresno.CA V,722 Nnrth;air I nkp t)T PAW54 Yuba Cita.CA x59$1
<br /> zt- (5113)562-1781 (5501275-0994 (801)938-1555 (6301700-(1170
<br /> g T531.7SlOST25 TSIOST 22 Class V Inorlerstion P-6,P-115
<br /> F- Pprrnit*A IA19
<br /> a TREATMENT FACiLiTY:i Certify ffltst I have been authorized by the applicable State agency t9o9ccIs
<br /> pt untreated Medical wastes and that I have
<br /> F- received the above indicate as in accordance with the requirement outline at a r ation. A r t
<br /> Pdninypa Nam. yC Signature Dat. AU6 9 1
<br /> ORIGINAL.
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