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MEDICAL WASTE TRACKING FORM NUMBER
<br /> �►®i• Stericyclw IN CASE%EMERGVCY nTATT:CHEMTREC 1.004-234-40S1 STANDARD MANIFEST 001-10-08-STO
<br /> ®• M1otertlny ka,k.Rrdauaq Mbt: K(lttt@' 4]..i MDR7L007C5L
<br /> I 1.Generator's ATTN Address and Telephone Number III MINOR
<br /> IWill
<br /> hill 1111111
<br /> ARBOR CO3itr33.USCENr PITAL
<br /> 900 T(t3RTB CRURCR 3TIRM
<br /> LORI, CA 95240
<br /> (209) 333-1222 5/l/2009
<br /> CUSTOMER NUMBER 6041015-001 GENERATOR'S REGISTRATION A
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C.NO.OF 20. VOLUME
<br /> REGULATED MEDICAL WASTE,n.c.s.,6.2, !ll a-{Ei a) 'J'.I+ls-(@Ntb) !u 9a1 Tab (5.9 as !t) CONT INERS p I Q
<br /> UN 8291,PG 11 t( ' 0 Cu Fl,
<br /> REGULATED MEDICAL WASTE,a.0.9.,e.2, TB21-(930) T615-(Path) f TY15-(Chaco) 20 Gal Tub (2.7)
<br /> UN 3291,PG Ii Cu Ft.
<br /> REGULATED MEDICAL WASTE.n.o.s,tlii TB49-{si 0) TP49-(Pa th) Ty49-4C]heao) 37 Gal TUU (4,9)
<br /> p UN 3291,PG it - Cu Ft.
<br /> REGUt ATED
<br /> Q MEDICAL WASTE,n.o.s.,6 2,
<br /> UN 3291,PG It Cu Ft.
<br /> U REGUtATED MEDICAL WASTE,o,o.s.,s.2, Tt357 - 94 rel 'Tub (Rio)4) (az cu 1 t)
<br /> lZ UN 3291.PG II
<br /> Gu F!.
<br /> REGULATED MEDICAL WASTE,n.os.,6.2, Tp64 - 48 Gal Tub (Bio) (6.4 cu ft)
<br /> UN 3291,PG II
<br /> Cu F6
<br /> REGULATED MEDICAL WASTE,n.o.s..6.2, $P96 _ 96 Gal Tub {Bio) ( ft)UN 3291,PG It Cu Ft,
<br /> REGULATED MEDICAL WASTE,n.os.,6.2, ST64 - 64 Gal Tub (Bio) (cu ft)
<br /> UN 3291,PG 11 Cu Ft.
<br /> Wme
<br /> Cu Ft.
<br /> 3.Generator's Cer6Nication:1 hereby dadare that the contents of this consignment are fully and accwateiy TOTALS111- Cu Ft.
<br /> describe we by the proper hipping name,and are ctassified,packaged,marked and labelledlpfacarded,and
<br /> are in all speck m pro anrding to applicable international and national gavernmentat regulat�."
<br /> - I Prin me S amore � Dene � '
<br /> 4.TRANSPORT���? � Phone N:
<br /> W ��•Ic�c Applicable Permit Numbers:
<br /> �o� 11875 iiltitc� Rork Rd � TttLs 1.s a Tht:oug!h 53ni.ptaant
<br /> g Rancho Cordova,CA 95742
<br /> �cn
<br /> nQ TRANSPORTER CERTIFICATION:Receipt of ma icaI wasie as described above.
<br /> Print/type NamoSignature Date d
<br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: V Phone W
<br /> a Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PdnNlype Name Signature Date
<br /> ih s.INTERMEDIATE HANDLER 3 tTRANSPORTER 3 ADDRESS: Phone k'
<br /> V4 CC ADpticable Permit Numbers:
<br /> °w'� INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> � s
<br /> l - Print(Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Transferred Berl, CU 4 to' NOM Safi ,UT
<br /> A.Designated Facility. $B.Alternate Facility: SC-Alternate Facility: 80.Alternate Facility:
<br /> 1945
<br /> CYCLE.INC. 41135W,sANve re 5'TERICYCLE.INC, 3 CYCLEAC.
<br /> a
<br /> Son LMrnlndro, 72�!IaSMST
<br /> ,CA 93M 90 NortFt 11I� 4512 Stair Or
<br /> NOM Salt Lake.UT 84054 Yuba M.CA 1
<br /> (510)562-1781 75-0994 (801)as-INS (530)780-x3170
<br /> T531.MOMS r 22 Chm V I P-S.P-11 I s
<br /> 141
<br /> N30U 91vis ld ! P11IM111091M
<br /> w
<br /> TREATMENY�$C;1�IT�13,r}�wa� been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br /> received the abbove to I e rdance with the requirement outilned in that authorization.
<br /> ,
<br /> I Printfrype Name,!t 1 Signature Date
<br /> .r
<br /> {!`sLSC1(Z) i
<br /> 'A,
<br /> ORIGINAL
<br /> fatt
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