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— MEDICAL WASTE TRACKING FORM NUMBER <br /> O**O Stericycle' IN CASE OF EMERGENC OH Cr:CHEMTREC 1-11IM23�0051 STANDARD MANIFEST 001-10•or-STtr <br /> ine,.ctrrrwct,.RV&'*,us,: Rause #: 4�1 MDRC006XXL <br /> � isGenerator's Name,Address and Telephone Number <br /> ATTN. Ann 1! E <br /> OR CONVALESCENT HOSPITAL <br /> 00 NORTH CRURca STRh""!aT <br /> DI, CA 95290 . <br /> (209) 333-1222 1/16/2009 <br /> CusTomeR NUMeenGENERAToa s ReetsTRAnoN If <br /> 2A.DESCRIPTION OF WASTE 001T28. CONTAINERTYPE 2C. NO.OF 21D. VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2 <br /> CONTAINERS <br /> ON 3291.PG It 57 - 90 Gal Tub (Elio) (12 cu ft) Cu Fr. <br /> REGULATED MEDICAL WASTE,n.o.s.,6. 14 - 44 Cal Tub (bio) (5.9 Cu It) ,�, Cur FI. <br /> ON 3291,PG 11 <br /> REGULATED MEDICAL WASTE.n.o.s.,6. <br /> 0 ON 3291,PG 11 21 - 20 Gal Tub (Bio)(2.7 cu Lt) Cu Ff. <br /> Q <br /> REGULATED MEDICAL WASTE,11-0-s-.6.4 49 - 3-7 Gal Tub (Bio), 10.7 La (4.9 CU ft) <br /> jr ON 3291,PG II Cu Ft, <br /> LUW REGULATED MEDICAL WASTE,n BIS - 20 Gal Tub (Path) (2.7 cu tt) Cu FI. <br /> ON 329f,PG II <br /> Q REGULATED MEDICAL WASTE,n,as.,6.2 <br /> ON 3291,PG 13 i5 ^ 20 pal Tub (Chemo) (2.7 cu ft) Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6. <br /> ON 3291,PG if 1935 26 Gal Tub (Si.o) (3.5 cu ft) Cu FI. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> I UN 3291,PG 11 Cu Ft. <br /> ! <br /> Phi rrnacetificall Waste Cu R. <br /> 3.Generator's CertlRcation:11 hereby declare that the contents of this are fully an a uralely TOTALS® �d Cu Ft. <br /> described above by the proper shippfag name,and are classified, ged,me t acarded,and <br /> are in all respects in proper condition for transpsn acro I g 1a i ble int dna mmental regulations' <br /> 13 I Printedirlwed Name Q�� S i Date <br /> 41.TRANSPORTER 1 ADDRESS: Ptuone(916) 985 - 5506 <br /> M¢t STERICYCLE Applicable Permit Numbers: <br /> 0 11875 White Rack Rd ThiVia Shipment <br /> Thcou h <br /> a. Rancho Cordova CA 95792 9 <br /> pac TRANSPORTER CERTIFIGATI :Rept ofedical waste as described sDove. <br /> cc P <br /> Prin1/1'ype Name- 8Signature Date <br /> IN 5.INTERMEDIATE HANDLER 2 1 THANSP014TER 2 ADDRESS: Phone a: <br /> e.1§ Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt o1 medical waste as described above. <br /> Print(Type Name Signature Dais <br /> 6.INTERMEDIATE HANDLER 3(TRANSPORTER 3 ADDRESS: Phone t: <br /> a Applicable Permit Numbers: <br /> rs <br /> i QL5Z <br /> Er INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> a <br /> — PrintliypeName Signature Date <br /> T.DISCREPANCY INDICATID'. ITSi +.yy <br /> I Y� �tP1'�id OQlitaine�'S, � `�.P CU A t11i : Nor(h San lake,U7 <br /> 008191tated Facility: El 88.Altornate Facility: ni 8C.Alternate Facility: eD.Aitemato Facility: <br /> ' CYC�.E INC. ICYCLE,INC. RICYCI.E,INC. 5TERICYCLE.INC. <br /> a 5 oi�sfe D&O,Su(te C A 35 W.Swig Avenue NOM 1100 4Wst 2715 E.20:treat <br /> u, an Lea 94577 F esno.CA 93722 o St>rtt take:UT 84054 Vernon,CA 90023 <br /> 151 aj 56 j`� t > }2as-Hasa sorb)23G- t s (323)360.aaszo <br /> 3I.1`SilO:iT25 ST 22 latae V Inclneraafin P-8,P-115 <br /> -02 <br /> a TR ATMENi" ALILI7Y:t1 rCl that I have been authorized by the applicable state agency to accept untreated medical wastes and that i haus <br /> I- received the above indicated wastes In accordance with the requirement outlined in that authorization. <br /> :I,:'r ZjIALSPRGtit <br /> Print/Type Namd Signature Date <br /> 00 498 <br /> ---- ---- —— _ —— - ®RIGINAI _ _...___ — _ _ratfae 14Jvt-"M _ <br />