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MEDICAL WAS E TRACKING 1F6RM N AIIIIit <br /> ®®Y 5tericycle' IN CASE OF EMERGENCY CONTACT:CMEMTREC 4-NO-234.0051 STANDARD MANIFEST 00mOV&STO <br /> Route #= 9k2S 1 I7 C-90 YE? <br /> i1.Generator's Name,Address and Telephone Number <br /> ATTN: Ann <br /> ARSOR CONVALESCENT HOSPITAL <br /> 40 NORTH CHURCH STREET <br /> ODI, CA 95240 <br /> (209)_--323-1222 1/22/201D9 <br /> CUSTOMER NUMBER GEN€RATows REwsTRATioN a <br /> i <br /> 2A.DESCRtPTtON CONTAINERTYPE 2C.NO.OF 20, VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, CONTAINERS <br /> UN 3291,PG ItTubL-u :EtjCu Ft. <br /> REGULATED MEDICAL WASTE,n.D.s,6.2, <br /> UN 3291.PG If qB14 - 44 Gal Tub Bio (5.9 cu ft) Cu Ft. <br /> REGULATED MEDICAL WASTE,rt s.,6.2, <br /> Q UN 3291,PG II 821 - 20 Gal Tub (18io)(2.7 cut ft) Cu Ft. <br /> €' ccH REGULATED MEDICAL WASTE,n,os„6 <br /> UN 3291.PG 11 B49 - 37 Gal Tub (Bib), 10.7 GB (4.9 cu ft) Cu Ft. <br /> U.1 REGULATED MEDICAL WASTE,n.D.s„6.2, <br /> I W UN 3291,PG II 15 - 20 Gal Tub (Path) (2.7 au £t) Cu Ft. <br /> REGULATED MEDICAL WASTE,n.D.s.A2, <br /> II UN 3291,PG 11 Cp Ft. <br /> REGULATED MEDICAL WASTE, <br /> UN 3291,PG 11 535 _ Cu t <br /> REGULATED MEDICAL WASTE,e,o.s.AZ <br /> UN 3291,PG N Cu Ft. <br /> Ph,mimetrileal waste <br /> / Cu Ft. <br /> 3.Generator's Cortincatlon:•I hereby declare that the Contents of this Consignment are fully arac-c IOTA ! •�` Cu Ft. <br /> aeserbed above by the proper shipping name,and are classified,packaged,marked and Iabellare in all respects In proper condition for transport according to applicable international and naanta on~ I Printedlfyped Name �+F'�' ILLr,�1� 5 pate ,L,C�Q1 <br /> W 4.TRANSPORTER 1 ADDRESS: Phone x'916) 985 - ,5546 <br /> STERICYCLE V Applicable Permit Numbers: <br /> Y lE <br /> 11e75 Waite Rock Rd <br /> C a This is a Through Shipment <br /> RanChb COCCIOVa,Cao 93742 <br /> cc <br /> TRANSPORTER CERTIFICA N:Receipt of medical waste as described e. <br /> Prfntlfyps Name Signature Date <br /> S.INTERMEDIATE HANDLER 2 lTRAf1SPORrER ADQRESS: Phone 4: <br /> Nle Applicable Permit Numbers: <br /> INTERMEDIATE HANDIER/TRANSPORTER CERTIFICATION:Receipt of medleal waste as described above. <br /> PdnNType Name Signature Date <br /> 8.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phare t: <br /> gcc Applicable Permit Numbers: <br /> L <br /> LQ <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> v Printlfype Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transferred containers. cu It to : North Salt lake.UT <br /> yr1455 <br /> Designated Facility: 80.Alternate Facillty: aC.Alternate FacMty at).Altemate Facility: <br /> -J �Irvt I F INC RICYCLE,INC. STERICYCLE.INC. STERICYCLE,INC. <br /> U RAAIMP I416WO Rrwta r 4 '4A W AwiftAwpnma en idarth 4400 Y4wc c 277€I-.=th%rpo <br /> 'Q amed a.0A 84btl7 K 'CA 02722 <br /> !if ntm f9AR r.7KP f!T rKsirKa Vcmon.GYt 90Os?a <br /> 502-17 , y ' S9y 2T5'-t)99Q p l)939-1535 f3231 352-30M <br /> .TS108T� k�' i '. QST 22 Glass V Intneratian f'-6,P-115 <br /> _ - ppm”Ai-ft? <br /> i ul INS$ QLk :�'G'� t i �o <br /> Tt3dATtl4E ARIL TY; carts tt',at I have been aUtttOeitk;d by the applicable stale agency t0 accept untreated medical wastes and that 1 have <br /> received the above.indicated Wastes in accordance with the requirement outlined in that authorization. <br /> :.L,Ur.'1 C1'-. <br /> PdnVType Name Signature Date <br /> ORIGINAL rpttitel.EG54f',td �1•.1afNYA1 <br />