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MEDICAL WASTE TRACKING FORM NUMBER
<br /> OWO Stericycle IN CASE of wAERGENGY CON]ACT_GkEMTREC 1-804.234-0051 STANDARD MANIFEST 001.10.06•STD
<br /> ( :• ro,.nbvxea+•.caa.ae,W�t' routs {#} [4( bb L MDRC006UAF
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ATTR: Ann III II 111 II II IIIEll illi 111111 Oil II
<br /> ARBOR CONVALESCENT HOSPITAL
<br /> 900 NORTH CHURCH STREET
<br /> LODI, CA 95240
<br /> (209) 333-1222 12/12/2008
<br /> � C y C n-t 1
<br /> CustomenNumsER 6041015-00 J. GENERATOR'SRErAsTRATWN#
<br /> 2A.DESCRIPTION OF WASTE 2a. CONTAINER TYPE 2C.NO.OF 2D. VOLUME
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, TB57 - 90 Gal Tub (Bio) (12 Cu ft) CONTAINERS k
<br /> UN 3291.PG If Cu Ft. €
<br /> REGULATED MEDICAL WASTE.n.o.s.,6.2, TE14 - 44 Gal Tub (Bio) (5.9 Cu ft)
<br /> UN 3291,PG If FI•
<br /> M REGULATED MEDICAL WASTE,mos.,6.2, TB21 - 20 Gal Tub (Bio)(2.7 cu ft)
<br /> 0 UN 3291,PG 11 Cu Ff.
<br /> Q REGULATED MEDICAL WASTE,n.os.,6.2, TH49 - 37 Ual Tub (Ba-911, Cu
<br /> UN 3291,PG li Cu FL
<br /> W REGULATEDMEDicALWASTE,n.o.s.,6.2, 1BI5 - 20 Gal xub {Path) (2.7 Cu ft)
<br /> W UN 3291,PG U Cu Ft.
<br /> Vr REGULATED MEDICAL WASTE,n.o.s.,6.2, TY15 - 20 eal Tub (Chemo) {2.7 cu ft)
<br /> UN 3291,PG II Cu Ft.
<br /> t REGULATED MEDICAL WASTE,n.o.s.,6.2, T035 - 26 tial Tub (Rio) 0.5 cu ft}
<br /> UN 3291,PG 11 Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> I UN 3291,PG 11 Cu Ft.
<br /> I arida @ C9 9 8
<br /> uF.
<br /> 3.Generator's Certification:'I hereby declare that the contents of this consignment are fully and accurately T®TALS ® /( u Ft.
<br /> described above by the proper shipping name,and are classified,packaged,marked and iabeiled/p9acerded,and
<br /> are in all respects in proper condition sport accordiD oo,applicable international and national govammen egWations"
<br /> !� jo
<br /> �u Y Printe ped Name Signature Date
<br /> Q UOUID
<br /> 4.TRANSPORTER Phone N:
<br /> >- 11875 Whit: Rack Rd ® .his in a 'Through shipment Applicable PemtitNumbers:
<br /> 1 Rancho Cordova,CA 95742
<br /> Q TRANSPORTER FIC ON:R ipt�modical waste as doscribe a
<br /> Pr#nlJiype Na" Signs a Data_ a! 1
<br /> S.INTERMEDIATE HAN LER 2/TRANSPORTER 2 ADDRESS: Phono N:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> P1intfType Name Signature Date
<br /> M 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone N:
<br /> $� Applicable Porntit Numbers:
<br /> �o INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> I.DISCREPANCY INDiCATtON Cans TT'8 -cont21 ner8, t`,.EI R to : N01'tht a @k-e 1 UT
<br /> �- A.Designated Facility: 88.Alternate Facility: 4C.Alternate Facility: 8D.Altemata Facility-
<br /> , S1ICYC INC. STERICYCLE,INC. STERICYCL.E,INC, STERICYCLE,INC.
<br /> U,
<br /> 1 Ot'W9,Sults C 4135 W..SwIRAvenue 00 North I IGO1,Neet 2775 E.26th actrAet
<br /> 4Zue+ ' as G.Q•.,•,D,A oa'fsA Martin*OR aHB.Ur 040" wumm,,oa *=am 1038)273-0884 (Sat)we-i«L$'S (3231362-3000 -
<br /> zMMT25 1 SMT 22 Class V IndrterilljOn P-6,P-t Is
<br /> Peon 91-02
<br /> TRE ''TY:,t car i(y that i have been authorized by the appticaUte stator agenkyr to accept untreated medical wastes and that I have
<br /> t- receivei�lhe a ted wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type N ` Signature Date
<br /> „
<br /> 00049 5-
<br /> ORIGINAL
<br />
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