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MEDICAL WASTE TRACKING FORM NUMSM <br /> Stericycle' IN CASE OF EMERGENCY CONTACT:CHEMTREG STANDARD MANIFEST 001-1"O.STO <br /> '•' n«<N�hwu�.�uigRhA: Route #: 413 9 800-424--9300 MLIRC£I08RKJ <br /> 1.Generator's Name,Address and Telephone Number91 <br /> 1 ® <br /> lI , ATTN: Ann jr ji <br /> ARBOR CONVALESCENT HOSPITAL <br /> 900 NORTH CHURCH STREET <br /> LODI. CA 95240 <br /> (209) 333-1222 3/12/2010 <br /> CUSTOMFR NUMBER G£N£RATOR'e RHGismmoN 1 <br /> 2A.08SCRIPTION OF WASTE F-TB21- <br /> CONTAINER TYPE 2C.NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,n.o,S.,52 CONTAtNERS <br /> UN 3291,PG 11 -o TP14-(Path) 44 6a1 Tub (5.9 eta ft) , <br /> REGULATED MEDICAL WASTE,n.o.s.,62Gu Fl <br /> UN 3291,PG 11 (Bio) / T)315-(Path) / TYlS-(Chemo) 20 Gal Tub (2.7CutL <br /> REGULATED MEDICALwASTE,n.o.s.,5.2, TB49� o ( at ) / -(Chemo) au ( . <br /> (3 UN 3221,PG II Bi ) / TP49- PhTY49Ch37 Gal Tub( Cu Fl. <br /> Q REGULATED MEDICAL WASTE.n.e.s.,6.2, TB25 - 26 Gal Tub (Bio) (3.5 cu ft) <br /> cc UN 3291,PG 11 Gu Ft <br /> W REGULATED MEDICAL WASTE,n.e.s„62, <br /> Z UN 3291.PG If TB57 - 90 Gal Tub (Bio) (12 cu ft) <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, Cu FL <br /> UN 3291,PG It TB64 - 48 Gal Tub (Bic) (5.4 cu ft) Cu FL <br /> REGULATED MEDICAL WASTE,n.o.s..6.2, <br /> UN 3291,PG It ST96 - 96 Gal Tub Bio 17.78 cu ft) Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG It 3T64 - 64 Gal Tub (Bic) (9.67 cu ft) <br /> hafTnaceutical Waste Cu Fc. <br /> c <br /> 3.GeneratoOs Certification."1 hereby dedgre that the contents of this consignment are fully and accurately TOTALS 0-- 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 International and national govemm regut tions” <br /> Printed/TypedNarhe Signatur Data <br /> cc 4.TRANSPORTER 1 ADDRESS: Phone <br /> L�'16) 985 - 5506 <br /> Appikreble Permit Numbers: <br /> cc 11875 White Rock Rd <br /> n a 3TERICYCLE This is a The ugh Shipment <br /> nxN <br /> a Q TRANSPORTlI QLtR�I FR&i&pt8 801,waste as described abo <br /> Print/Type Name Signature Date <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 A DRESS: Phone rf; <br /> N <br /> ,r Applicable Permit Numbers: <br /> INTERMEDIATE HANDLE i A/N/SPO /�ER CERTIFICATION:R ' i of m I sons described above. <br /> Print/Typo Name !t( a Signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone Y: <br /> lag g Applicable Permit Numbers: <br /> O INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> illd <br /> Prinu yp o Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transferred' container's, ou R to : North Salt take, UT <br /> SA.Destgnaled Factlity: E18B.Alternate Facility: 8C.Alternate Facility: 0 60.ANmato Facalty: <br /> STERICYCL.E.INC. STERICYCLE.INC. S�ERIGYJ6W�NC. �GYCIS INC. <br /> toy 1345 Doolittle Drive,Suite C 4135 W.Swift Avenue Orth t est �+ fair r ' <br /> San Leandro.CA 94577 Fresno.CA 93722 North Salt Lake,UT 84059 Yuba Ct'ry,GA 9500t <br /> (510)582-1781 (560)275-4904 (801)936-1555 (630)790-0170 <br /> W TS34.TS10ST25 MOST 22 Ctass%I tnanetattan Pearl+.#91 P-6,P-445 <br /> P11. '? <br /> TREATMENT FACILITY:I certify that 1 have been authorized by the applicab ata a " oto accepl untreated medical wastes and that I have <br /> received the above in ed s in acoordance with the require in [n�Qg 4g <br /> Print/Type Name ca � Signature Date IAAR (" `u <br /> 000463 <br /> t, ORIGINAL rptlde Std nv-u,< <br />