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MEDICAL WASTE TRACKING FORM NUIMBERµ <br /> 0 0 0 Stericycle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-600^234.0651 STA€YDARO MAN(FEST 001.10-00•STO .• <br /> a A r t r+ror.R.aanrMw: Route 413 `1 <br /> M.DRC007ZEI <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN: Ann <br /> ARBOR CONVALESCENT HOSPITAL <br /> 900 NORTH CHURCH STREET <br /> LODI. CA 95240 <br /> 2091- 333-1222 9 18/2009 <br /> CUSTOMER NUMBER _ GmuwTows REGISTRAmm 4 <br /> 2A,DESCRIPTION OF WASTE 2a. CONTAINER TYPE 2C. NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s..6.2, coNTAI ERS <br /> UN 3291,PG If TP14-(Bath) 44 Gal Tub (S.9 cu ft:) .(4P CU Ft. <br /> REGULATED MEDICAL WASTE,n.os.,6.2, <br /> UN 3291,PG II TB21-0io) / TB15-(Path) / TY15-(Chemo) 20 621 Tub (2.7 CU Ft. <br /> ix REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> Q UN 3291,PG if T194 9-(Bio) / TP49-(Path) / TY49-(Chemo) 37 Gal Tub (4.9 Cu Ft. <br /> REGULATED MEDICAL WASTE,n.as..6.2, TB35 - 26 G21 Tub (Bio) (3.S cu ft) <br /> M UN 3291,PG II Cu Ft. <br /> WREGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG if TB57 - 90 Gal Tub (Bio) (12 cu ft) <br /> W <br /> �+ REGULATED MEDICAL WASTE,n.e.s.,6.2, Cu Ft. <br /> UN 3291,PG 11 TE64 - 48 Gal Tub (Bio) (6.4 Cu fix) CUB. <br /> REGULATED MEDICAL WASTE,n.e.s.,6.2, <br /> UN 3291,PG if 11hCu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,Pei II ST64 - 64 Gal Tub Bio 9.67 cu ft) Cu Ft. <br /> Pharmaceutical WaFte <br /> ep Cu Ft. <br /> 3.Generator's Certification:'I hereby declare that the contents of this consignment are fully and accuratelyTOTALS 10, 43: Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and labelledtptacarded,and <br /> are In all respocts in proper cpndion for transport aocwding to applicable International and national gover ental regulations" <br /> iPriMe ped Name t '"-° ( `t Signature D to <br /> 4.TRANSPORTER 1 ADDRESS: K; <br /> w AppllcWQrmI?#&bars:5`06 <br /> rr 11875 White Rock Rd <br /> CLST£RICYCL£ X Thaw im a Through Shipment <br /> a 4% TRANSPORTraosxii 9'e xpit waste as describedabo <br /> Printlfype Nam �H Signature Date 'f .Q <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: V Phone e: <br /> n <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Pdnveype Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone a: I <br /> Applicable Permit Numbers. <br /> $ INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> 49= <br /> Print/Type Name Signature Date <br /> T.DISCREPANCY INDICATION <br /> Transferred containers, ou ft to. North Salt lake, UT <br /> Deafgnated Fedilty: 88.Alternate Facility; 0 SC.Alternate Facility: go,Alternate Facility: <br /> oil <br /> RICYCLE.INC. STERICYCLE.INC. STERICYCLE,INC. STERICYCLE,INC. { <br /> LL 1345 Dooliute Drive.Suite C 495W.Swift:Avenue 90 North 11100 West 1012 Starr Dr <br /> San Leandro.CA 94577 Frew.CAA 93722 North Salt Lake,UT 84054 Yuba CtiW,CA 85991 <br /> IJU (510)682-1781 (559)275.0994 (801)938-1555 (530)790-0170 <br /> HTS31.TS10ST263 TS(OST 22 ClassV lndnerAen PenyiW 91 P-6, 40 <br /> it TREATMENT FACILITY:I certify that 1 have been authorized by the appticabl state I to accept untreated medical wastes and that I have <br /> H received the above ind eddstes in accordance with the requirem fined 1 066 tion. p <br /> !It <br /> PrintrType NamIDIDA� Sigruuure Data SE r 2009 <br /> G00452 (� <br /> ORIGINAL E <br />