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—'—�— T MEDICAL WASTE TRACKING FORM NUMBER <br /> p S4erlcycte' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1.1100.234.0051 STANDARD MANIFEST 001.10-0eSTO <br /> ®,, r�rwMrrrocr+.R.aaru' Route #: 413 -1 MDRC00852L <br /> 1.Generator's NTelephone Number <br /> MTN, Ann <br /> ARBOR CONVALESCENT HOSPITAL <br /> 900 NORTH CHURCH STREET <br /> LODE. CA 95240 <br /> (209) 333-1222 10/30/2009 <br /> CUSTOMER Nur,tarm 6041015-001 GENERATows REoisTRATION M <br /> 2A,DESCRIPTION OF WASTE 29. CONTAINER TYPE 2C.NO.OF 2D. VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, CONTAI SRS <br /> UN 3291,PG 11 / TP14-EPathj 44 Bal Tub (5.9 cu ft) Cu Ft. ' <br /> UN 3291 <br /> REGULATED MEDICAL WASTE,n.0.s.,6.2, TB a o) / TB1S-(Path) / TY15-(Chemo) 20 Gal Tub (2.7 l <br /> PG 11 - Cu Ft. <br /> ® REGULATED MEDICAL WASTE,n.O.s..6.2, TB49-(Bio) / TP49-(Path} / TY49-(Chemo) 37 Gal Tub (4.9 <br /> UN 3291,PG 11 Cu Ft, <br /> REGULATED MEDICAL WASTE,n.o.s..6.2, T535 - 26 tial Tub (Bio) (3.5 au ft) <br /> UN 3291,PG fl Cu Ft. <br /> W REGULATED MED6:ALWASTE.n.o.s.,6.2, TB57 - 90 Gal Tub (Bio) (12 au ft) <br /> Z UN 3291,PG 11 Cu Ft. <br /> LU REGULATED MEDICAL WASTE,n o.s.,62 <br /> UN 3291,PG 11 TB64 - 48 Gal Tub (Bio) (6.4 cu ft) Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.A.2, <br /> UN329t,PGit ST96 - 96 Gal Tub (Bio) (17.18 au ft) Cu Ft. <br /> REGULATED MEDICALWASTEn.o.s.,6.2, ST64 - 64 Gal Tub (Bic) (9.67 au ft) <br /> UN 3291,PG Ii Cu Ft. <br /> PhanTiacetlticai Waste Cu <br /> F <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and acevrately TOTALS► 5' 2 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 intemational and national governor n[at regulations" <br /> fPrintwitped Name Signature Data <br /> 4.TRANSPORTER I ADDRESS: one(r 16) 985 - 5506 <br /> Applicable Permit Numbers: <br /> 11875 White Rock Rd <br /> P,'S'£AICY'CL£ X This is a Through Shipment <br /> a°c,z TRANSPORT ARCskI gf*46al waste as described above. /} p lye <br /> Print/Type Name Signal." Date -�4 t.3Q'6 f <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone rf: <br /> Nil Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Roeaipt of medical waste as described above. <br /> Print/lype Name Signature Data <br /> M 6.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone Ir: <br /> Applicable Permit Numbers: <br /> 0 <br /> INTERMEDIATE HANDIER/TRANSPORTER CERTIFICATION:Recalpt of medical waste as described above. <br /> Z T <br /> pdnwryfe Mme Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transferred containers, ou ft to : North Salt lake,LST <br /> 8A,D"Itinated Faculty a6.Altarnale Facility: ❑ac.Apemate Facalty: so.Atbamate Facility <br /> STERICYCLE.INC. STERICYCLE.INC. STERICYCLE INC. S'TERiCYCLSE,INC, <br /> 1345 Doolittle Drive.Suite C 4135 W.SwittAvenue 90 North i 1001%st 1612 Starr Cir <br /> San Leandro.CA 94577 Fresno.CA 93722 North Salt Lake,UT 84054 Yuba C*ftv.CA 95991 <br /> (510)562 1784 (559)275-0994 (801,1938- 1555 (530)790-4110 <br /> LU TS31.TS(OST25 MOST 22 C(assld lncinecation Pec tx#91 P-6,P-1 i5 <br /> ,Q I <br /> W TREATMENT FACILITY: erti that 1 have been authorized by the applicable State agent to accept untreated medical wastes and that I have <br /> received the abo ted es in accordance with the requirement outli In ttla arizalion. I <br /> PrInVType Name '' signature Date NOV 0 3 2009 <br /> 00 0-37 4 <br /> ORIGINAL rrdFiYe)lanSEiEdStd �T-r1U <br />