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MEDICAL_WASTE TRACKING FORM NUMBER <br /> •"e•1 <br /> 11 sterieyeilr Rafti'sf?F fb%R1*NCYcoN?%LC. WEER � a3i MDRC(ft0jj AN1FEsr001-10-06-STO <br /> ft o. OA: <br /> 1.Generator's Name,Address and Telephone Number <br /> riT` t'.: Ann <br /> ARBOR CONVALESCENT HOSPITAL <br /> 900 NORTH CHURCH STREET <br /> LODI, CA 95240 <br /> (209) 333-1222 1/5/2011 <br /> CusromrnNumann 6041015-001 G rM"R'eReorsTMnoro0 <br /> 2A.DESCRIPT1T10N OF WASTE 2e• CONTAINER TYPE 2C. NO.or 2D. 1rflt,WE <br /> UN3291,Regulated Medical Waste,n.o.s.. 9-(B ) 1 T214-(Path) 44 Sal Tub (5.9 Cu ft) CONTAINS \7 <br /> 6.2'PGII J $, <br /> Cu Ft. <br /> UN3291,Regulated Medical waste,n.o.s., TB21-(Bio) / T]315-(Path) / 7y15-(Chemo) 24 Gal Tub (2.7 <br /> 6.2,PGII Cu Ft. <br /> ! Cr UN3291,Regulated Medical Waste,n,o.s.. T849-(Bio). / Tr49-(Fath) / TY49-(Chemo) 37 Gal Tub (4.0 <br /> Q fit,PGII <br /> QCu Ft. <br /> UN3291,Regulated Medical Waste,n.o.s., - a xo Cu <br /> cc 62,i'GI! Cu Fr. <br /> til UN3291,Regulated Medical waste,n,o.s., TB57 - 90 Gal. Tub (Bio) (12 cu ft) <br /> 2 62,PGII <br /> � <br /> UN3291.Regulated Medica!Waste,MOS.. TB64 - 4E Gal Tub (Bio) (6.4 cu ft) Cu Ft, <br /> 6.2,PGE1 Cu Ft. <br /> UN3291,Regulated Medical waste,n,o.s., 9T96 - 96 Gal Tub (Bio) (17.78 cu ft) <br /> 62,PGI l Cu Ft. <br /> N3291i Regulated Medica!Waste.11.0-5., 3T64 - 64 Gal Tub (Bio) (9.67 au ft) <br /> armace ca a e Cu Ft. <br /> fa Ft. <br /> 3.Generator's Certificatlon:'I hereby declare that the contents of this consignment aro fully and aoctrrataly TOTALS It ~ Cu FI. <br /> descrip d above by the proper sht name,and are classified,packaged,marked and labelled/placar and are i ail espects In proper on tranepar cling to applicable Into natkmal and national rn ental regulations" <br /> Pn d LMAN Signature <br /> 4.TRANS RTER 1 ADDRESS: p"i6) 885 - 5506 <br /> 11875 White Rock Rd Appkable Permit Numbers: <br /> a STE CYCLE c K Thin i rough i not <br /> 0j057dg <br /> a� TRANSPORTER i�C ttciptror medical waste as described <br /> off' ,� _ .✓ <br /> PrinUrype Name t^^ Signature Dale <br /> 5,INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS; Phone d: <br /> �-' Applicable Permit Numbers: , <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Rocelpt of medical waste as ascribed above, <br /> PrIM/rype Name Signature Date <br /> s.INTERMEDIATE HANDLER 3/TRANSPORTER 3ADDRESS: Peep; <br /> a Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt or medical wasla as described above. <br /> PrinVryps Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transferred Containers; rpt ft to : North Salt lake,UT <br /> .Designated Faciihy: ea.Alternate Facntty: ❑0-C.AltenraN Facility: so.Aftn%ats Facility: <br /> "^a STERICYCLEANC. ' STERICYCLE.INC. STERICYCLE,INC, STERICYCLE.INC, <br /> 1345 Doolittle Drive.Suite C 035W.Sw tAvenue 90 North 1100 West 1512 Starr Dr <br /> San Leandro.CA 94677; Fresno,CA 93722 North Salt lake;UT 84064 Yuba Cl'ry,CA 85991 <br /> (510)552-1781 (659)275-0994 (801)03B-1655 (530)755-0685 <br /> TS31.TS(OST25 MOST 22 Class V Incineration PemliW 91 P.O.P-115 <br /> uuTREATMENT FACILITY: !Certify that 1 have been authorized by the applicable state age�jr ccyy to accept untreated medical wastes and that I have <br /> received the above Indicata4d wasibs In accordance with the requirement ou onedliin th t,quthdrization. <br /> l Print/rypa Name of Signature u t'� ^-t Date <br /> JAN 0 6 2011 <br /> ORIGOM <br /> rxtl3l: S!d ni..t� <br />