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ME0lCAL WASTE TRACKING FORM NUMBER <br /> ®®019 Stericycle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1$00.234-o0S1 STANDARD MANIFEST 001.1046-STO <br /> • "todnjt`°"`,."""*"VA: Route is 425 1 MDRC006RRB <br /> 1.Generator's Name,Address and Telephone Number <br /> A=>TH: Ann 111111101111111111 lol{UUIg1111 t111ii iN 8111111 <br /> fffflf ilii f ilii ifili! <br /> ' ARBOR CONVALESCENT HOSPITAL <br /> 900 NCATE CHURCH STREET <br /> ODI, CA 95240 <br /> 2093 333-1222 11/18/2008 <br /> CUSTour;R NUMBER _ GENERATOR'S REGISTRATION R <br /> 60 31.03Iq2A.DESCRIPTION OF WASTE 2t3. CONTAINER TYPE 2C.NO.OF 2D. VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s.A.2 CONTAINERS <br /> UN 3291,PS If B57 " 90 Gal Tub (Bio) (12 Cu tt) Cu <br /> REGULATED MEDICAL WASTE,mos.A. Ft <br /> UN 3291.PG 11 14 - 44 Qat Tub (Bio) (5.9 cu ft) <br /> Cr. REGULATED MEDICAL WASTE,mo.s.,6. . Cu Ft. , <br /> Q UN 3291 PG II 821 - 20 tial Tub (Rio) (2.7 Cu ft) <br /> Q <br /> Co Ft.REGULATED MEDICAL WASTE,n.o.9.,6. 849 _ 37 Gal `Pub (Si*), 10.7 L5 (4.9 cu tt) <br /> p: UN 3291,PG 11 Cu Ft. { <br /> it1 REGULATED MEDICAL WASTE,n.o.s.,6.2 <br /> Z UN 3291,PG if 815 - 20 041 Tub (Path) (2.7 cu !t) <br /> REGULATED MEDICAL WASTE,n,o.s..6.2. Cu Ft. <br /> UN 3291,PG II 15 - 20 Gal Tub (Chemo) (2.7 cu St) Cu Ft <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2 <br /> UN 3291,PG II 63S - 26 Gal Tub (Bio) 0.5 au tt) Cu Ft. <br /> REGULATED MEDICAL WASTE.n.o.s..62, <br /> UN 3291,PG if <br /> Ph IrmaceulkA Waste 2.— L <br /> cu FL <br /> •py U <br /> 3.Generator's Certification:"I hereby declare that the contents of this lgnment ate Idly and accurately TOTALS® /. Cu Ft. <br /> described Stave by the Draper shipping name,and are da '" d,pa g m and labe9etUplat arded,and <br /> are in ail respects in proper con ' fort r1 atxording o appl a I ternat� i and national ental r utatl <br /> 1 ' <br /> IP,Inted/Typed Name S nal e g <br /> Is <br /> 4.TRANSPORTER 1 ADDRESS: <br /> P <br /> STERICYCLE 85 5 6 <br /> 0 11875 White Rock Rd Applltable Perr mit Numbers: <br /> % Rancho Cardava,CA 45742 ® This is a Through Shipment <br /> Z TRANSPORTER RTI FlC TION-Recut of medical waste as descd ti <br /> Print/Type Name Snature . Date <br /> S.INTERMEDIATEr, <br /> FWDLM 2/TRANSPORTER 2 ADDRESS: Phone 4: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Rocapt of medical waste as described above. <br /> PdnV ype Name Signature Date <br /> Paaan 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: phone N: <br /> at Applicable Parmit Numbers: <br /> OLUO <br /> xZ <br /> za INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> . a <br /> Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATIO a� <br /> NT awainera, C1,1 a to, Norm SaRR Rake,tff 7- <br /> A.Designated Facility: 96.Alternate Facility: C.Alternate FeClUty: 6O.ARemato Faclllty: <br /> CYCLE INC. [CYCLE,INC, CYCLE.INC. STERICYCLE,INC. <br /> to 1345 D�o�ro�d�iC�lert`1nrberer,sub C 35 W.S6a�Qt Avenue SQ Ntrfth 1100 2775 E.261h Sired <br /> W 8 °eV ndm.CA 54577 a CA 93122 Plant SO Uka UT &ou Vlrmw^n,CA Mn <br /> Z 51�fl)66 #)N1 ( 9j 275-!3994 (BE3 i i 9'sn•1650 i,soi 36Z-3t7t'3a <br /> W 31.sc?, 1" 22 CImV Indnembn P-6,P=115 <br /> JIB P 91-02 J <br /> t Fas:'Ct kRV:if[k rtify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> t- received the above indicated wastes in accordance with the requirement outlined in that authorization. <br /> 01* 11TALSERGER <br /> Pdnt/Typs Name Signature Date <br /> !I 0-Q <br /> I <br /> l <br /> ORIGINAL <br /> � t..3yillrh.�0f1 <br />