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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 4�p Stericycle' ,C s F F GE11CY CONTACT UTff V""4_"0()
<br /> S7MGI.IANtFEST 001•10 O6 STD
<br /> 1.Generator's Name Address and Telephone Number
<br /> 'll
<br /> T
<br /> Ari'RI. Ann ' 111111 1 fill,
<br /> ^' "" n,,,, 1111111I111111�111111111181111111fIi1111111loll IN111III
<br /> ARBOR CONVALESCENT HOSPITAL
<br /> 900 NORTH CHURCH STREET
<br /> LODI. CA 95240
<br /> (209) 333-1222 9/22/2010
<br /> CUSTOMER NUMBER 6041015-001 GEwRAtmR'S REOIsTRATioN s
<br /> 2A.DESCRIPTION OF WASTE 2 CONTAINER TYPO: X.NO.OF 20. VOLUME
<br /> UN3291,Regulated Medica!Waste,n.o. - f TP14-(Phth) 44 Gal Tub (5.9 cu ft) CONTAINERS
<br /> 6.2,PGII • 9 Cu Ft.
<br /> UN3291 Regutaled Medical Waste,n.o.s., T621-(Bio) / TBl5 (Path) / TY15-(Chama) 20 Gal Tub
<br /> f 6.2,PG11 Cu Ft.
<br /> JIB UN3291,Regulated Medical Waste,n.o.s., TB49-(Bio) / TP49•-(Fath) / TY49-( emO a
<br /> 1 6.2,PGII Cu Ft.
<br /> UN3291,Regulated Medical Waste.n.o.s., - a .'o t au
<br /> cc 6,2,PGII
<br /> Cu Ft.
<br /> W UN3291,Regulated Medical Waste,n.o.s., TB51 - 90 Gal Tub (Bio) (12 ou ft)
<br /> W 6.2,PGII Cu Ft.
<br /> V. UN3291,Regulated Medical Waste.n.o,s., TB64 - 48 Gal Tub (Bio) (6.4 Cu it)
<br /> 6.2,PG II Cu Ft.
<br /> 623PGIiRegulated MeditalWaste,n.o.s„ ST96 - 96 Gal Tub (Bio) (17.7(1 cu it)
<br /> Cu FL
<br /> UN3291,Regulated Medical Waste,n.o.s., ST64 - 64 Gal Tub (Sia) (9.61 au it)
<br /> 6.2,PGII Cu Ft.
<br /> Ptiarniaceutical Wa6te
<br /> c� Cu Ft.
<br /> v e v accurately TOTALS► / jam T`
<br /> 3.Generator's Certlflcatfon:"!hereby declare that the contents of this consignment are full and actxtrate � Cu Ft.
<br /> described above by the proper shipping name,and ate classified.packaged,marked and'lahelled/placarrled,and
<br /> are In aft respects in proper condition for transport according to applicable Intern tional and national governmental regulations'
<br /> - I PrintediT ped Name Signature Date
<br /> a 4.TRANSPORTER t ADDRES Phone(ag16) 985 - 5506
<br /> ru
<br /> 11875 Wh;it� Rock Rd
<br /> Applicable Permit Numbers:
<br /> B`1'£RTCYCLTr X Thus ire a 7`hrau h �fTipme:lt
<br /> CL
<br /> CL aZ TRANSPORTER FftTftT-*' I S Udi to as described above. s ^?
<br /> PrinUTypo Name .fJ �'SJgmature Dato
<br /> 5.INTERMEDIATE HANDLER 2/TRA SPORTER 2 ADDRESS: Phone M:
<br /> `Y Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:ReCeiptot medical waste as described above.
<br /> Print/Type,Name Signature Date
<br /> M 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone N:
<br /> cc I s Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recolpt of medical waste as described above.
<br /> s
<br /> Print!y e Name Signature Data
<br /> 7.DISCREPANCY INDICATION
<br /> Transferred containers, cu 1t to : North Salt lake, UT
<br /> signaled Peclilry: 69,Alternate FACltlty SC.Aitemvw Facility: BD.Alternate Facility
<br /> jj STERICYCLE.INC. STERICYCLE.INC. STERICYCLE,INC. STI BICYCLE,INC.
<br /> 1346 Doolittle Drive.Suite C 4135 W.Swift Avenue 90 North 1100 West 1812 Starr Dr
<br /> San Leanclro.CA 94577 Fresno.CA 93722 North Salt Lake,UT 84054 Yuba C''ty,CA 95991
<br /> Z (610)562- 1781 (559)275-0994 (801)936-1656 (530)755-0585
<br /> uj TC44.TQI(1rSrncr 7s
<br /> 2 dzv lt3ci%erty% ?et #04 P-6,?-415
<br /> v, ,v.,.qT)�;T�>;v
<br /> Q
<br /> I TREA"i MENT FACILITY:i cern that have been authorized by the applicable stale ncy t pt untreated medical wastes and that I have
<br /> i received the above indica StMrw��e�oqjg'.".
<br /> ocordance withhthe requirement ou ' at au n. S p q
<br /> ` PrJnUTypeName rh.� Date SEP 2 2�1�
<br /> u C! d L
<br /> I ORIGINAI.
<br /> I r0i3ctaareS01549Ed 9rl•l�
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