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<br /> MEDICAL WASTE TRACKING FORM NUMBER
<br /> 00 , STANDARD MANIFEST 001-10,0"TD
<br /> 0®w Stericycle' IN CASE EMERG CY TA .CHEMTREC 1-600.234 /
<br /> •• hoteclMohaPk.MMKMORhf. outa ': �' MDRC007DGS
<br /> 1.Generator's Name,Addrss and Telephone Number
<br /> KTTbt ) � J
<br /> ARBOR CONVALESCENT HOSI?I:TAU 4 11
<br /> 904) NORTH CHURCH STREET
<br /> LORI, CA 95290
<br /> (209) 3331222 5/8/2009
<br /> CUSTOMER NUMBER 6091015-001 GENERMOR'S REGIMATION 0
<br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO.OF 2D. VOLUME
<br /> REGULATED MEDICAL WASTE,R.o.s,.6.2, T314-(8jo) / TF14-(Bath:) 44 6a1 Tub (5.9 au ft) CONTAINERS
<br /> UN 3291,PG II Cu FL
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, TB21-(Bio) / TB15-(Path) / TY15-(Chemo) 20 Gal Tub (2.7)
<br /> i UN 3291,PG IITBCu F!.
<br /> j CC REGULATED MEDICAL WASTE.n.o.s..6.2, 49-{Bio} / TP99-(Path) / TY49-(Cheiao) 37 Gal Tub (4.9)
<br /> 0 UN 3291,PG 11 Cu Ft.
<br /> rIx REGULATED MEDICAL WASTE.n.o.s.4.2. a u z c eu
<br /> Cu Ft.
<br /> UN 3291,PG II
<br /> W REGUtATEDMEDICAL WASTE.n.o,s.,6.2, TB57 - 90 Gal Tub (Bio) (12 au ft)
<br /> 1Z UN 3291,PG€1 Cu Ft.
<br /> REGULATED MEDICALWASTrio.s..6.2, TB64 - 48 Gal Tub (Bio) (6.4 cu ft)
<br /> UN 3291,PG II Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2. ST96 - 96 Gal Tub (Bio) (cu ft)
<br /> UN 3291.PG 11 Cu Ft.
<br /> REGULATEDMEDICAL WASTE,n.o,S.,6.2, ST64 - 64 Gal Tub (Bio) (cu ft)
<br /> UN 3291,PG II Cu FL
<br /> I
<br /> Cu Ft.
<br /> 3.Generator's C01`11111110111011*"I hereby declare that the contents of this consignment are Wily and accurately TOTALS® Ft
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelfedipfacarded,and
<br /> are in all respects In proper condition for transport according to applicable international and national goner me regulations"
<br /> Printedlf ed Name � Signature Dale
<br /> 4.TRANSPORT 2F'iSLE Phone it: ) 9 - 06
<br /> 11875 White Rock Rd Applicable Permit Numbers:
<br /> Thi
<br /> Q Rancho Cordotra,CA 95742 This i5 Through 3hipmcnt
<br /> 5:N
<br /> 0QC TRANSPORTER C RTIFECATI N:Receipt of medicat waste as described above. 5,19 q
<br /> ~ Pdnt/rypo Name Signature Date -® F
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTE:R 2 ADDRESS: Phone M:
<br /> 51 Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PrinYType Name Signature Date
<br /> I M12 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 8:
<br /> Applicable Permit Numbers.
<br /> } ¢ INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> ,
<br /> Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Transferred containers, tat It to : North Salt lake,UT
<br /> A.Designated Faculty, Be.Aitemate Facility: 0 8C,Alternate Facility: 8D.Alternate Facility:
<br /> Rir W:i TERICYCLE,INC. STERICYCLE.INC. STERICYCLE,INC.
<br /> 4145 Doral 3S yllvifsAvenue 8Q Norttl !fQ0 lht?st #892 Starr Dr
<br /> San Leandro,GA h"" Fremo.CA 95722 Wnrth c,;tt t Rkp I IT RAIf94 Yuba Citv.CA 95991
<br /> i (510)582-1781.. (559)275-0994 (so i)936-1555 1'6301790-0170
<br /> Z TS31.TSt0S1 QU301VIS 14101 TSIOST 22 Class V In1
<br /> incineration P-6,P- 15
<br /> Lu
<br /> r i, PPrM*#A147
<br /> I
<br /> TREATMENT FACIU :tZ e1it r a Kve been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> 1Ix
<br /> .- received the abgv»indicaied_.wwastes in accordance with the requirement outlined In that authorization.
<br /> PdnVrypo Name `"'Z ' Signeturo nate
<br /> ORIGINAL rr(Rtoltarl5�lS(d t!fi u,�,71>tti4
<br />
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