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MEDICAL WASTE TRACKING FORM NUMBER
<br /> fA S4ericycle INCAS T �RCi�N Y,aVN?CT:CNEMTREC1.800.234.0051 Mp ;J�Qg1;t�AtAtdIFESToof•Se•OBS7D
<br /> n.r�cproa�c.rN ap,xr: flfl v�+/U,7lY
<br /> 1.Generator's Name,Address and Telephone Number
<br /> I ATT14: Ann
<br /> OR CONVALESCENT HOSPITAL
<br /> 00 NORTH CHURCH STREET
<br /> ,ODI, CA 95240
<br /> (209) 333-1222 2/13/2009
<br /> I
<br /> CuswMIM NuraaEa 6041015-0 01 GENEanoa'S REGfSTnA7toN to
<br /> 2A.DESCRIPTION OF WASTE 29, CONTAINER TYPE 2C.NO.OF 21). VOLUME
<br /> REGULATED MEDICAL WASTE,n.ox,,6. CONTAINERS
<br /> UN 3291,PG 11 57 - 90 Gal Tub (Bio) (12 cu ft)
<br /> Cu FL
<br /> REGULATED MEDICAL WASTE,n.o.s.,ii. 14 - 44 Gal Tub (Bio) (5.9 Cu ft)
<br /> UN 3291,FG II Cu Ft,
<br /> DC REGULATED MEDICAL WASTE,n.os.,6.
<br /> UN 3291,PGI I %21 - 20 Gal Tub (Bio)(2.7 Cu ift) Cu Ft.
<br /> Q
<br /> siREGULATED MEDICAL WASTE,n.o.8..6. 49 - 37 Gal Tub (Bio), 10.7 LB (4.9 cu ft)
<br /> UN 3291,PG II Cu Ft.
<br /> EA!
<br /> REGULATED MEDICALWASTE,n.o.s.,6. 15 - 20Gal Tub (Bath) (2.7 Cu t`.t)
<br /> W UN 3291,PG 11 Cu Ft.
<br /> REGULATED MEDICAL WASTE.n.os.,6. 15 - 20 CTaI Tttb (Cttema! (2.7 cu ft!
<br /> UN 3291,PG II Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o,s.,6, 35 - 2�i Gal Tub {Bio) (3.5 cu ft)
<br /> II UN 3291,PG It Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> j UN 3291,PG ii Cu Ft.
<br /> Ptv mTecoulical West
<br /> C
<br /> 3.Generator's Certificatlon:'I hereby declare that the contents of this consignment are Luny and accurately TOTALS` i Cu Ft.
<br /> described above by the proper shipping name•and are classified,packaged,marked and fabebiedlplaoarded,and
<br /> are In all respects in proper condition for transport according to applicable International and national governmental regulations."
<br /> NA'Printed/T ped Name Si naturecocac_ Data+� '3-Q
<br /> 4.TRANSPORTER t ADDRESS: Phone b b
<br /> STOIC ' Applicable Permit Numbers:
<br /> a 11875 White Rock Rd
<br /> c oThis is a Through Shipment
<br /> Raancho Cordova,CA 95742 nx
<br /> a d TRANSPORTER CERTIFICATIQ :Receipt of medical waste as described a
<br /> Printtfypa Name P"moijd ,_Signature Date
<br /> 5.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone#:
<br /> N
<br /> I§ Applicable Permit Numbers:
<br /> I
<br /> ri INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of rneftat wasto as described above.
<br /> Pdnt/Type Name --,--Signature Date
<br /> M 6.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Plane e:
<br /> rar$tr Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER ITRANSPORTER CERTIFICATION:Receipt of medical waste as described above,
<br /> Prinvfte Name Signature Date
<br /> 7.11 DISCREPANCY INDICATIONtli'afts ferred Coritalnal'S, CU A to ! North haft lake,UT
<br /> A.Designated FaeBity: E1813.Allamets Facility: 80.Alternate Facility: 8D.Alternate Faonity:
<br /> 'TRICYCLE.INC. S TERICYCLE,INC. 16MIN
<br /> ERICYCI.E,INC. (�,✓� S�RICYCLE,INC.
<br /> v 346 Daaams Dave,Sults C 4135 W.SWIRAVOrWo North 1 too West `-- � rSd eel
<br /> u an Leandro.C.A 94577 F esno.CA 93722 tth Sett Lake.LIT 84054 6 A 91)023
<br /> 5 t 0)562- t781 ( 59)275-0994 01)636-1665 (323)362-3000
<br /> w 31,TS/OST25 MOST 22 assVIndneralban ��tJ�faB
<br /> 91-02 00::6
<br /> TREATMENT FACILITY:i certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that t have
<br /> received the above indicated wastes in accordance with the requirement outlined in that authorization
<br /> Print/Type Name Signature
<br /> ORIGINAL, gAR1a Sid IS-Feb-2009
<br />
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