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MEDICAL WASTE TRACKING FORM NUMBER
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<br /> Eti ®41 Stericycle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-8e0-23"051 STANDARD MANIFEST 001.10.06-STO
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<br /> ~.• r,.,..uo .`w•a Route #: 413 -1 i[ ( ( [MDRCOOSAF9
<br /> i.Generator's Name,Address and Telephone Number
<br /> ATTN: Ann
<br /> ARBOR CONVALESCENT HOSPITAL
<br /> 900 NORTH CHURCH STREET
<br /> LOBI, CA 95240
<br /> (209) 333--1222 11/2'7/2009
<br /> CUSTOMER NUMBER 604101 -001 GENsftmo 's REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAMERTYPE 2C.NO.OF 21D. VOLUME
<br /> REGULATED MEDICAL WASTE,wo.s.,6.2, CGNT ERs
<br /> UN 3291,PG If 14-(Bio) / TP14-(Path) 44 gal Tull (5.9 cu f$) _ Cu Ft.
<br /> REGULATED MEDICAL WASTE,n,o.s•,62, TB21-(Bio) / T615-(Fath) / TY15-(Chemo) 20 Gal Tub (2.7
<br /> UN 3241.PG II Gu Ft.
<br /> CC REGULATED MEDICAL WASTE,n.o,s..6.2. TB 9-(Bio) / TP49-(Path) / TY49-(Chemo) 37 Gal Tub (4.9
<br /> ® UN 3291,PG 11 Cu Ft.
<br /> Q REGULATED MEDICAL WASTE,n.o.s.,62, TB35 - 26 Gal Tub (Bio) (3.5 cu ft)
<br /> CC UN 3291,PG II Cu Ft.
<br /> LU REGULATED MEDICAL WASTE,n.o.s.,6.2, TBS7 - 9D Gal Tuts (Bio) (12 cu ft)
<br /> LAj
<br /> Z UN 3291,PG II Cu FI.
<br /> REGULATED MEDICAL WASTE,
<br /> UN 3291,PG11 TB64 - 48 Gal Tub (Bio) (6,4 cu ft) Cu Ft.
<br /> REGULATED MEDICAL WASTE,n,o.s.,6.2,
<br /> UN 3291,PG 11 ST96 - 96 Gal Tub Bio 17.78 au Et Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, $T64 - 64 Gal Ttah (Hie) (9.67 ata ft)
<br /> UN 3291,PG II Cu FL
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<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS® Cu F1.
<br /> described above by the proper shipping name,and are classifled,packaged,marked and Iabelied/piacarde.1 and
<br /> are I1xn all respects in proper condition for transport according to applicable international and national governmental r ulatlons*
<br /> [Prime Name OnC ��� Signature �t Date
<br /> ` 4.TRANSPORTER 1 ADDRESS: 56
<br /> Phone SD
<br /> ua Appli^a rm 1 umt>Exs:
<br /> arc 11875 White Rock Rd
<br /> 90
<br /> CL Q This in a Through Shipment
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<br /> ME
<br /> TRANSPORTEMEMIP7lrr'Arilxp�iptSfal r2atwasteasdescdbeda
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<br /> Printlrype Name Signature Data
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<br /> 5.INTERMEDIATE HANDLER 2/T ANSPORTER 2 ADDRESS: Phone#:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recut of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 5,INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#;
<br /> Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Reoelpt of medical waste as described above.
<br /> PrinUType Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Transferred containers, ou ft to : North Salt take, UT
<br /> A.Designated Facility: 86,Alternate Fac6ity; 6C,Alternate Facility W.Alterna/a Faculty:
<br /> STERICYCL.E.INC. STERICYCL.E.INC. STERICYCLE INC. STERICYCL.E,INC.
<br /> 1:3
<br /> 45 nnnOtlp nrivo Rnita r 4135 W.Swift Avenue GUN Orth 1100 West 1612 Starr Dr
<br /> Gan I pandrn CA A4577 Frpcnn ('A 0797 North Sah Lake UT 84054 Yuba QW,CA 95891
<br /> Z (5101562-1781 (559)275-0994 (801)936- t 65N (530)790-0170
<br /> T!RR1 T WngT?5 TS/OST 22 Classy Incineration f'elmit#91 P-B,P-115
<br /> UJI TREATMENT FACILITY:I certify that I have been authorized by the applicable state agenc tcapt untreated medical wastes and that I have
<br /> received the above indicate dyaast n accordance with the requirement cull' that tion.
<br /> -- `../ I DEC U 2449
<br /> Prinittype Name '�'" r Signature G rf Date
<br /> ORIGINAL , rolRtc 164S1a �3 u, - '
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