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___—_� -- --- - - - MEDICAL WASTE TRACKING FORM NUMBER
<br /> O-0
<br /> Q steritytie' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-806-234-DOSI STANDARD MANIFCST 001.10.00-STD
<br /> I o o Route #: 425 -2 MDRC006ZDO
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ATTN: Ann � 1
<br /> kRBOR CONVALESCENT HOSPITAL
<br /> 00 NORTH CAURCR STREET
<br /> f ODI, CA 95240
<br /> !f (209) 333-1222 1/30/2009
<br /> 1
<br /> ' CUSTOMER NUMBE 1015 001 GENenATows REGISTRAMN 0
<br /> 2A.DESCRIPTION OF WASTE 28, CONTAINER TYPE 2C.NO.OF 20. VOLUME
<br /> REGULATED MEDICAL WASTE,n.o.s.,6. BST _ 90 Gal Tub (Bio) {32 cu ft) CONTAINERS
<br /> UN 3291,FG it Cu R.
<br /> REGULATED MEDICAL WASTE,n.d.s.,G.
<br /> UN 3291,PG It 614 - 44 Gal Tub (Bio) (5.9 Ct,1 Et) 5 �'r
<br /> 'J ,,Cu Ft,
<br /> i fr REGULATED MEDICAL WASTE,mo.s.,6- B2l - 20 Gal Tub (Bio)(2.7 Gu Ltj -lip
<br /> O UN 3291.PG II
<br /> I Cu Ft.
<br /> Q REGULATED MEDICAL WASTE,n-0-1-6-21 849 — 37 Gal Tub (Bio), 10.7 LE (4.9 cu ft)
<br /> UN 3291.PG 11 Cu Ft.
<br /> 111 REGULATED MEDICAL WASTE,n.o.s.,6, 81S - 20 Gal xtlb (Fath} (2.T Cu ft)
<br /> W UN 3291,PG ii Cu Ft.
<br /> REGULATED MEDICAL WASTE, 15 - 20 Ciel Tub (CtltaxoD 12.7 cu ft)UN 3291,PG 11 Cu FL
<br /> REGULATED MEDICAL WASTE,n.o.s.,6. 835 - 2B Cia3 Tub (Bioj (3.5 cu ft)UN 3291,PG It Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> UN 3291.PG it Cu Ft.
<br /> Phi rmeceutical Waste
<br /> Cu Ft.
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are sully and accurately TOTALS® r 9 Cu Ft
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and
<br /> are In all respects In proper condition for transport according to applicable international and national governmental regulations:'
<br /> I f
<br /> Printed/Typed Name —Signature Date ` �
<br /> 4.TRANSPORTER 1 ADDRESS: Phons X916) 985 - 5506
<br /> STETC YCLE Applicable Permit Numbers-
<br /> 11875 1IB75 White Rock Rd This is a Through Shipment
<br /> M.(% Rancho Cordova,CA 96742
<br /> Q Q TRANSPORTER C RTIFICA O :Receipt of medical waste as described
<br /> Print/Type Noma Signature Date
<br /> b.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#;
<br /> N
<br /> cc Applicable Permit Numbers:
<br /> „GGff INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of meckal'waste as described above.
<br /> a
<br /> Print/Type Name Signature Date
<br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone q;
<br /> ¢�a Applicable Permit Numbers:
<br /> p�G
<br /> Q. INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> a
<br /> a- Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATIO, _tsftrad t7G11t1 roam, eI h to: North Salt take,UT
<br /> SA.Designated Facility: 813.Altemate Facility; 8C.Alternate Faetllty: 8D.Artamate Facility:
<br /> BICYCLE (CYCLE,INC. R{GYCLE,ING. STERICYCLF,INC.
<br /> 345 DoollBle -8i,1� W.9�kAVenue 0 North 1100 West 2775 E.20 Shot
<br /> LL Leandro, 945 .� F sno.CA 93722 Orth Salt Lake,UT 84Q54 Vemon,CA 90023
<br /> z 510)562- 1781 830ega-I'.+.S E � 59)275-0934 80 1)836-1 555 (323)362-3000
<br /> u 31,7'5108!25 T 22 lam V Indneratlon P-6,P-t SS
<br /> TREATMENT ENT FACILITY:t certify the , ve been authorized by the applicable state agGnCy to accept untreated medical wastes and that I have
<br /> I'- received the above-indi a tqd wastes In accordance with the requirement outlined in that authorization,
<br /> Print/Type,Name Signelure Date
<br /> r.
<br /> j ORtt31I11AE. rdt11@t,t7►-2tbs_ __
<br />
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