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1I MEDICAL WASTE TRACKING FORM NUMBER <br /> o <br /> • Stericyde' IN CASE OF EMERGENCY CONTACT CHEMTREC 1.600.234-0051 STANDARD MANIFEST oot•to.W.STO <br /> '•`# "•"""""°'""'' Route 0: 425 -4 MDRC006S6H <br /> 1.Generator's Name,Address and Telephone Number <br /> ATN: Ann <br /> kRBOR CONVALESCENT HOSPITAL <br /> 900 NORTH CHURCH STAT <br /> ODI r CA 95240 <br /> (209) 333-1222 11/21/2008 <br /> CU5Tt7YEA NUM9ER A 1 n 1 1r;_ GENEAArows RcmisTRAnoN 0 <br /> 2A.DESCRIPTION OF WASTE 20. CONTAINER TYPE 2C. NO.OF 20. VOLUME <br /> ! REGULATED MEDICAL WASTE,1I.D.S.,6.2. CONTAINERS <br /> UN 3291,PG II 1857 - 90 Gal 'Cub (Rio) (12 cu ft) Cu Ft. <br /> I REGULATED MEDICAL WASTE,n.0.8.4. C�i <br /> ` UN 3291,PG N B14 - 44 Gal Tub (Bir,) (5.9 cu tt) / Gu Ft. <br /> I= REGULATED MEDICAL WASTE,tt.o.s.,6. <br /> 0 UN 3291,PG 11 B21 - 20 Gal Tub (Bio)(Z,7 cu It) <br /> Cu Ft. <br /> i Q REGULATED MEDICAL WASTE,n.os.,62 S44 - 37 Gal Tub (Bio), 10.7 LB (4.9 cu ft) <br /> UN 3291,PG 11 Cu Ft. <br /> W REGULATED MEDICAL WASTE,n.o.s.,6.2 815 20 Gal Tub (Bath} (2.T cu it} <br /> UN 3291,PG I! Cu Ft. <br /> W <br /> Wr REGULATED MEDICAL WASTE,n.os„6.2, <br /> UN 3291.PG II 1YIS - 20 Gal Tub (Chemo) 12.7 cu ft) Cu FL <br /> REGULATED MEDICAL WASTE,n.D.s.,6.2 <br /> UN 3291,PG If 835 - 26 G.I. Tub {Sio) (3.5 cu ft) Cu Ft. <br /> REGULATED MEDICAL WASTE,n.e.s.,6.2, <br /> UN 3291,PG 11 Cu Ft. <br /> Ph rmacatnfcel Waste <br /> 1 Cu Ft. <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS (r j Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and labeliedtp€acarded,and <br /> are In all respects in proper condition for transport according to applicable international and national governmental regulations` <br /> I•�PrintedrTyped Name G t/ —signature 104A04Z —Dais -o <br /> 4.TRANSPORTER 1 ADDRESS: Phone x(916) 995 - 5506 <br /> STMCYCLE Applicable Permit Numbers: <br /> a 11875 White Rock RdQ This is a Through Shipment <br /> rrn Rancho CordovarCA 95742 <br /> a q TRANSPORTER CERTIFIC TI N:Receiptof edica€waste as described a ve, <br /> cc <br /> PrInUType Name Signature Date <br /> /J•21-0$ <br /> 5.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone N: <br /> \ N <br /> W V Applicable Permit Numbers: <br /> g INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION:Receipt of medical waste as described above, <br /> Printflype Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3ITRANSPORTER 3 ADDRESS: Phone fl: <br /> II t Applicable Permit Numbers: <br /> oWd <br /> AU INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Raceiptof medical waste as doscnbod above. <br /> Z9 x <br /> PrInt/Type Name Signature Date <br /> T.DISCREPANCY€NDICAT!0i�1MBS f9rmd comalnem, cu ti to: Nanh^watt lake,UT <br /> $A.Designated Facility: 88.Alternate Facility: U 6C.Akemate Facility: So.Ansrnete Facility: <br /> CYCt INC. RICYCLE,INC, STERICYCLE,INC CLI!,INC. <br /> 1345 Doolittle Dry,Sutm C 35 W.SwRA"nue 90 NOM I IGO Mat W40 Street <br /> an LeatltirD,t:A 84577 sno.CA 93722 Vernon,CA 90023 <br /> Nalth aP11119ke.i 17 640 <br /> Z (610)552-1761 ( 99)275-0994 (801)935-1555 2l392i31;lV,f323).062-3800 <br /> W TS31.TSIOST25 ST 22 ClalssVlndnenitUon . _ P-6,P-115 <br /> Petri”91-02- <br /> i W " TREATMENT FACILITY: I certify 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 authorizatiD / /0J <br /> I, <br /> PNnt(Type Name Signature Dale <br /> le <br /> t <br /> ORIGINAL .��tr+uar+lsr�std t8 tVon 701€77. <br />