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MEDICAL WASTE TRACKING FORM NIIMEIER
<br /> 0Re0 5tericytle' IN CASE OF EMERGENCY CONTACT.
<br /> CHEMTREC 1-800.234-0051 (��}( (�`,STANDARD MANIFEST001-10-06STO
<br /> Oe Proe 60re 0#Redadq Rhk.' Route Tf: 41.1 —1 MUfMd.0083 i1 —...,...
<br /> i.Generator's Name,Address and Telephone Number � � � �
<br /> ATTN: Ann 1IN
<br /> ARBOR CONVALESCENT HOSPITAL
<br /> 900 NORTH CHURCH STREET
<br /> LODI, CA 95240
<br /> (209) 333-1222 10/16/2009
<br /> CUSTOMER NUMBER ir.04 I nj 2:-, GENERATORV REGtSTRA"ON 0
<br /> 2A.DESCRIPTION OF WASTE 28. CONTAINERTYPE 20.NO.OF 2D. VOLUME
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, CONTAI RS ^j
<br /> j ON 3291,PG II 14-mw 'x'14-CPAtb} 44 Gal-Tah (3.9 cu ft) (.2. Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6 2, �,82z_{BiO) l X815-tPa Ch} / TY15 (4 hesao) 20 Gal Tub (2.7
<br /> UN 3291,PG II Cu Ft.
<br /> p[ REGULATED MEDICAL WASTE,mo.s.,6.2, T849-(Elio) / TP49-(Path) / 7Y49-(Chetaa) 37 Gal Tub 0.9
<br /> Q
<br /> ON 3291,PG It Cu FL
<br /> iC REGULATED MEDICAL WASTE,n.o.s.,6.2, TE335 - 26 Gal Tub (Bio) (3.5 Cu ft)
<br /> a: UN 3291,PG it Cu FL
<br /> tLI REGULATED MEDICAL WASTE.n.o,s.,6.2, T8S7 94 Gal Tub ($ia) (12 cu. ft)
<br /> W
<br /> ON 3291,PG II CU Ft.
<br /> u, REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> ON 3291,PG II T864 - 48 Gal Tub (flirt) (6.4 cu ft) Cu Ft
<br /> REGULATED MEDICAL WASTE,mo.s.,6.2,
<br /> ON 3291,PG it ST90 - 96 Gal Tub (17.78 cu ft CU Ft.
<br /> REGULATED MEDICAL WASTE,mo.s.,6,2, ST64 - 64 Gal Tub (Baa) (9.ti7 cu ft)
<br /> ON 3291,PG II Cu Ft.
<br /> hatmacetitiml W11sta
<br /> �7 Cu Ft.
<br /> 3.Generator's Certification:"i hereby declare that the contents of this consignment are fully and accurately T®TALS ► Cu FL
<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 govern tah Mations"
<br /> V
<br /> �a Printedfrypod Name Signature Data
<br /> a 4.TRANSPORTER 1 ADDRESS: Phon #: {1
<br /> F&rmA t7aAtohers:5.rjrtb
<br /> ¢etc 11875 White Rot* Rd ® This is a Through Ship>reent.
<br /> R STEMC7171LE
<br /> Z TRANSPORTER61150 am gerl4adi waste as described above. 10.1b
<br /> Printflype Name Signature Date / � LOL
<br /> 5,INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: V Phone#:
<br /> . Applicable Permit Numbers:
<br /> }}11!! INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> I ZGx
<br /> O�Sa Pdntf ype Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> M Applicable Permit Numbers:
<br /> cI
<br /> Rc' INTERMEDIATE HANDLER JTRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> - PtinV1W*Name Signature Date
<br /> -- 7.DISCREPANCY INDICATION
<br /> Ilk Transferred containers, ,a,fl t4 : North Salt lake,UT
<br /> iMo.Designated Facility: 88.Alternate Facility: U 8C.Alternate Facility: BD.Alternate Facility:
<br /> STERICYCLE,INC. STERICYCLE,INC. STERICYCLE,INC, STERICYCLE,INC,
<br /> 1345 Daatme 011VO,Suits C 4135 W.SvA Avenue 9D Nat9T 1100 West 1612 Starr Dr
<br /> San Leandro,CA 94577 Fresno.CA 937:2 North Salt lake.UT 84054 'Yuba fir,CA 95991
<br /> i (510)562- 1781 (559)276-0994 (801)936- 1555 (530)790-0170
<br /> g t TS31.TSSIOOS'T25 T SMT 22 Cass v Ino! nirtlsn Pgmt#9 1 P-u,P-I Is
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<br /> TREATMENT FACILITY:I Certl that I have been authorized by the applicable state agen�toqpttreated medical wastes and that I have
<br /> received the above indicat St accordance with the requirement outlined' at a {�
<br /> -f 3�nature
<br /> PdnUType Name Date l
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<br /> 000 4 2 9 i
<br /> ORIGINAL rottaatrtar�owl3d t3(11
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