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<br /> MEDICAL WASTE TRACKING FORM NUMBER
<br /> •«e• Stericycte' INCAS E OF SMERG Y CRJPr.CHEMTREC 1.804}234.00511 r1 t�Cf STANDARD MANIFEST001.10.06•STO
<br /> ®• naawpfeePh.tMvau,peaa; R4aute `ila"t 1 MDRC003M
<br /> 7.Generator's Name,Address and Telephone Number
<br /> nmTAt. Ann
<br /> ARBOR CONVALESCENT HOSPITAL
<br /> 900 NORTH CHURCH STREET
<br /> LOBI, CA 95240
<br /> (209) 333-1222 12/11/2009
<br /> CUSTOMER NINASER GENERATOR'S REOWMATION N
<br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO,OF 20. VOLUME
<br /> REGULATED MEDICAL WASTE,a.o.s.,6.2, CONTAINERS
<br /> UN 3291,PG 11 TB3.4--0io) / TP14-(Path) 44 Gal Tub (5.9 cu ft)
<br /> Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.iis..61 TB21-(Bio) / 2$15-{path
<br /> UN 3291,PG It ) / TY15-(Chemo) 20 Gal Tub (2.7
<br /> Cu FI.
<br /> Cc REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> Q UN 3291,PG Il TB49-(Bio) / TP49-(path) / TY49-(Chemo) 37 Gal Tub (4.9 '
<br /> Cu Ft.
<br /> Q REGULATED MEDICAL WASTE,a.o.s.,62, TB35 - 26 Gal Tub (Bic) (3.5 au ft)
<br /> fr UN 3291,PG II Cu Ft.
<br /> UJ REGULATED MEDICAL WASTE,n.o.s.,6.2, 2$57 - HO Gal Tub (bio) (12 cu ft) ,
<br /> W 11tH 3291,PG it _ Cu Ft.
<br /> Q REGULATED MEDICAL WASTE,mo.s.,6.2,
<br /> UN 3291,PG 11 TB64 - 48 Gal Tub (Bin) (6.4 ou £t) Cu FL
<br /> REGULATED MEDICAL WASTE,mo.s.,6.2,
<br /> UN 3291,PG rl - 96a Tub (Bio)( 17.78 au ft Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> LIN 3291,PG 11 ST64 - 64 Gal Tub (Bio) (9.67 cu ft) Cu Ft.
<br /> harmaceutical Waste
<br /> S.Generator's Certifleatton:"I hereby declare that tho contents of this consignment are fully and acotirately TOTALS ® Cu Ft,
<br /> described above by the proper shipping name,and are cfassllled,packaged,marked and labelled/placarded,and
<br /> are in all respects in proper condilion for transport according to applicablojitternational artd national governmental ul 'ons'
<br /> I Printed/T ped Name "-Mw Signataxe _ bats
<br /> 4,TRANSPORTER 1 ADDRESS: —Phone
<br /> 6: Date
<br /> Al905 - 5506
<br /> a 11875 White Rack Rd � Appticable bers:
<br /> =ami. STERICYCLE R1 Thin im a Through Shipment
<br /> N
<br /> a Q TRANSPORTSMSEW Et uiC*t9151 01 waste as described ab w.
<br /> Pdntfrype Name 4 Signature Date
<br /> S.INTERMEDIATE HANDLER 2!ThANSPORTEA 2 ADDRESS: VPhone e:
<br /> 9 Applicable Permit Numbers:
<br /> a
<br /> zI INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpt of medical waste as described above.
<br /> Print/rype Name Signature Date
<br /> �, 8.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone N:
<br /> Va Applicable Permit Numbers:
<br /> z INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> a x
<br /> is- Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> pa Transferred con#airters, cu ft to : North Salt lake,!JT
<br /> ❑8A.Designated Facility: 0 ae.Alternate Facility: 8C.ARemats Facility: 80.Alternate Facillty:
<br /> 1 STERICYCLE.INC. STERICYCLE.INC. STERICYCLE INC. STERICYCLE,INC.
<br /> (345 Doolittle Drive.Suite C 4435 W.Swift Avenue 9Q North 1100 Wes# 4612 Starr[Jr
<br /> San LeandraCA 84577 Fresno.CA 93722 North Salt Lake UT 84054 Yuba City,CA 95691
<br /> (51(11 582-1 784 (5591275-©994 (8011 938- 155 f5301790-0170
<br /> 1 S3!.TS/OSTZS MOST 22 ad sv Indswr4on Petra`((;:91 P-8,P-1 t6
<br /> Cc TREATMENT FACILITY:I certify that i have been authorized by the applicable tate a to accept untreated medical wastes and that I have
<br /> � received the above Ind' d tes in accordance with the requireme ned In rization. 2009
<br /> PrintfTypeName Signature Date DEC
<br /> 000GR 9
<br />
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