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0*0 0 MEDICAL WASTE TRACKING FORMNUMBER
<br /> 1010.0•0 Stericycle' IN CASE OF EMERGENCY CONTACT.
<br /> 2ONTACT.CHEMTREC 1-800• 1 STANDARD MANIFEST 001-ID-09-STD
<br /> X425
<br /> ® trofatagr pk.R,sWny,:,µ' RG11 b.� it
<br /> MDRcaa7o2W
<br /> 1.Generator's Name,Address and Telephone Number
<br /> OR CONVALESCENT HOSPITAL
<br /> as NORTH CRURCH STREET
<br /> t)ITI, CA 95240
<br /> (209) 333-1222 2/6/2009
<br /> CUSTOMER NUMa7WASTE,
<br /> nni GENERATOR'S REaIsrnAnOM#
<br /> 2A.DESCRIPTITE `28. CONTAINER TYPE 2C. NO,OF 2D. VOLUME
<br /> REGULATED MEDWASTE, .o.s.,8.2, CONTAINERS
<br /> UN 3291,PG II857 - 90 Gal Tub (Bio) (12 cu ft) Cu Ft.
<br /> REGULATED MED .o,s.,6.UN 3291,PG 11814 - 44 Gal Tub (Rio) (5.9 cu tt) ° - Cu FI.
<br /> tr REGULATED MEDICAL WASTE,n.01.,62
<br /> ® UN 3291,PG/ 1 B21 - 20 Gal Tub (Bio)(2.7 Cu ft)
<br /> Q UNREGULATED MEDICALWASTE,n.o.s.,6. 1149 - 37 tial Tub (Bio), 10.7 LB (4.9 Cu ft)
<br /> Cu Ft.
<br /> (� UN 3281,PG II
<br /> W REGULATED MEDICAL WASTE,n.o,s A2,
<br /> W UN 3291,PG If 815 - 20 Gal Tub (Rath) (2.7 cu It) Cu Ft
<br /> REGULATED MEDICAL WASTE,4.0.S.,6.2,
<br /> UN 3291,PG 11 1S - 20 Cal Tub (Chemo) (2.7 cu ft) Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.os.,6.2,
<br /> UN 3291,PG II IB35 - 26 tial Tub (Bio) (3.5 cu ft) Cu Ft.
<br /> REGULATED MEDICAL WASTE.n.o.5..6.2,
<br /> UN 3291,PG 1€ Ct.1 Fi
<br /> Phil neceidicul Waste
<br /> Cu
<br /> 3.Generator's Certlieation:11 hereby declare that the contents of this consignment are fully and amuratefy TOTCu 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 /> IPrinted(Typed Name Si nature e pate to 61
<br /> 4.TRANSPORTER iADDRESS: Phonef-916) 9B5 5506
<br /> y. STERICYCLE Applicable Permit Numbers:
<br /> a 11675 White Rock Rd [�
<br /> Rancho Cordova,C,A 95742 U ' is a Through Shipment
<br /> a TRANSPORTER CERTIFICATI N:Receipt of edicar waste as described a
<br /> P� type Name Signature Date
<br /> 5.INTERMEDIATE.HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> jign Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER ITRANSPORT•ER CERTIFICATION:Receipt of medical waste as described above.
<br /> PrinUType Name Signature Date
<br /> M 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#;
<br /> aIr Applicable Permit Numbers:
<br /> a
<br /> a.ma
<br /> a°C INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PdnVT pe Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> TWsfe�red containers, CU a to : North Salt take,UT
<br /> P3446
<br /> Designatad Facility: m
<br /> 88.Attaate Facility: 6C.Aftamate Facility: 80.Alternate Facility:
<br /> ICYCLE.INC. ICYCLE,INC. SIERICYCLE.INC. STERICYCI„E,INC.
<br /> 0 Doolittle DM,Sub C 4135 W,SWftt Am" 90 North 1100 West 2775 E.20 Met
<br /> rn Lae E F cane,CA 93722 North Sett Lake,UT 84054 Vernon,CA 90073
<br /> sl�Q)56 ( 59)275-13994 o 1)936- 1555 (323)362-3003
<br /> W1.,.TS=T2ST 22 C1assV Indneration P-6.P-115
<br /> /(� }y{}}►�+(�( I} [R��Wr' l 2�(�{ Pern i!#91.02 tt
<br /> TREATMENT FACILITY:I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received tqe}4pWj1bKNff%astes in accordance with the requirement outlined in that authorization.
<br /> Print/Typo Name _Signature Date
<br /> .�• ff
<br /> ORIGINAL
<br />
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