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®� ME:DICALWASTE TRACKING FO.RMNUM0ER <br /> A•® Sltericycle' 1N CASE OF EMERGENCY CQ(ixACT CtiE1tATREC 1 BUO 234u�51 STANDARD MANIFEST t�t.t0-0S$TO <br /> 6.0 rrm.aMnr�a�..Ked,d„gRhi' Routc �F '413 hDRCO 87B <br /> 1.Generator's Name,Address and Telephone Number l!i iiilllil[Iii/ ! ! tI J <br /> Arrmld• Ann li!11!l111111tIr�! IIII I III I! 11 I y# <br /> r%& &1% ss,.li III lIYollieli0iill III loll lilt ti I I <br /> ARBOR CONVALESCENT HOSPITAL <br /> 900 NORTH CHURCH STREET <br /> LODI, CA 95240 <br /> (209) 338-1222 11/13/2009 <br /> CUSTOMER NUMOER 6Q413GENERATOR's REGISTRATION <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 26. NO.OF 2D. VOLUME <br /> REGULATED MEDICAL WASTE,mo.s.,6.2, CONTAIN Rs Cu Ft. <br /> UN 3291.PG ft '4-(Si.o l TP14-(Path) 44 Gal Tub (S.9 cu ft) <br /> REGULATED MEDICAL WASTE,a,o.s.,6.2, <br /> UN 3291,PG Ei Bio) / TB15-(Path) / TY15-(Chemo) 20 Gal Tub (2.7 <br /> ( <br /> Cu F!. <br /> UN3291 <br /> TEDMfDtCALWASTE,n.o.s.,6.2, <br /> 0 T9-(BiTP49PhTY49-(Ch ) 37 Gal Tub (4.9 <br /> Q U N 3291.PG I I B4o) / -( at ) / emo <br /> Cu Ft. <br /> d REG ULATEDMEDICAL WASTE.o.o.S.,6.2, TB35 - 26 Gal Tub (Bio) (3.5 au ft) <br /> a UN 3291,PG it Cu Ft. <br /> 11] REGULATED MEDICAL WASTE,n.os..6.2, TB57 - 90 Gal flub (Bao) (12 cu t) <br /> UN 3291,PG II fCu Ft. <br /> REGULATED MEDICAL WASTE.n.o.s.,6.2, <br /> UN 3291,PG II TB64 - 48 Gal Tub (Bio) (6.4 au fb) Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG II STAS - 96 C Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG ii ST64 - 64 Gal Tub (Bio) (9.57 cu ft) Cu Ft. <br /> harmaceutical Waste <br /> I Cu Ft. <br /> 3.Generator's Certification:"I hereby declare that the Contents of this consignment are fully and accurately TOTALS ► Cu Ft. <br /> described above by the proper shipping name,and are desMied,packaged,marked and labelled/placarded,and <br /> fare In all respects in proper condition <br /> �for transport according to applicable international and national governmental regula Ions: <br /> l +PrinfedtfypedName�l��B�C' Qi Signature 4/1���/1JJf Date JLA "o <br /> 4.TRANSPORTER 1 ADDRESS: Phone t: 6 <br /> c�C 11875 White Ros~k Rd J Applic�9blaNnnIg IRIahbers:S506 <br /> 3 <br /> rn 'i RICYCt,E 2 '('his iu 2 Through Shipment <br /> a¢Z TRANSPORTEMSERN 81x1 ZI1 136T9i4�a1 wa a as described above. ; <br /> 3, �r"1 <br /> Printfrype Name ignature Rate V 1 <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone a: <br /> a Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Print/Typo Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 0: <br /> W Applicable Permit Numbers: <br /> R Vj E INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpt of nodical waste as descritwd above. <br /> 4C IPrinVType Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transferred containers, cu ft to : North Salt lake, LIT <br /> 8A.Designated Facility: aa.Alternals Facility: 8C.Alternate Facility! ®so.Alternate Facility: <br /> J <br /> � j <br /> v STERICYCLE.INC. STERICYCLE.INC. STERICYCLE,INC, STERICYCLE,INC. <br /> 1345 Doolittle Drive.Suite C 4135 W.SWIlAvenue 90 North 1100 West 1012 Starr Or <br /> San Leandro.GA 84577 Fresno.CA 93722 Nodi Salt Lake,LIT 64054 Yuba C' CA 95991 <br /> (51 01 582-1781 (559)275-0994 (80 1)938- 1655 (5301 790-0170 <br /> TS31. ST25 TVOST 22 class Indttecation Pena"8i 0-8"P-A15 <br /> TREATMENT FACILITY:I certify that I have been authorized by the applicable State agency to accept untreated medical wastes and that I have <br /> 10- received the above indlGated s in accordance with the requirement oulline in that riza6on. OV 16 20 <br /> Prirt/lypa Name / Signature Date <br /> ORIGINAL n s <br />