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---M - v -- MEDICAL.WASTE:TRACKING FORM NUMBER <br /> 0 w® Stericycta' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1.800.234 Ots51 STANDARD MANIFEST 001.10-0WSTD <br /> iii'v ,�.N., w.R Ala; Route #-. 41.3 3 MDRC007FTD <br /> 1.Generator's Name,Address and Telephone Number <br /> AM; Ann (( i( IN lull I <br /> ARBQR COWAL,ESCZYff BMPITAL <br /> 900 iKSI'tIR CIURCR S'IY1EEs"P <br /> WDI, (A 95240 <br /> (209) 333-1222 5/22/2009 <br /> CUSTOMER NUMBER GENeRA ows REOtSTRAnoN A <br /> 2A.DESCRIPTION OF WASTE 29. CONTAINER TYPE 2C. NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,fl.03..6.2, CONT HERS <br /> UN 3291,PG It 223.4-(BL►) 'VPU-(8'1011►) Sal 2ab (S.9 w Ixt) 5, Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, ?19x1-(Bits) J ?015-ilpath) / Tyt5-(C ePA1<) 20 Gal Tub (2.7) <br /> UN 3291,PG it Cu Ft. <br /> DC REGULATED MEDICAL WASTE,n.o.s.,6.2, T8l9^4810) / TP49_jPat.h) / TY49-(Chemo) 37 Gal Tub (4.9) <br /> 0 UN 3291,PG 11 Ca Ft. <br /> Q REGULATED MEDICALWASTE,n.o.s.,6.2. TV35 2Tu <br /> ti Gal b (gi.o) (3.5 Cu ft► <br /> DC UN 3291,PG g Cu Ft. <br /> W REGULATED MEDICAL WASTE,11.0s.A.2, T857 - 90 Gal tub (f3ia) (]8 Cu i t) <br /> W UN 3291.PG It II Cu Ft. <br /> UNUN 3291TED MEDICAL WASTE,n.as..6.2, Tv64 - 40 Gal tub (Bio) (6.4 cu it} <br /> 3291,PG Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG 11 GAL (Big) Cu ft Cu Ft. <br /> REGULATED MEDICAL WASTE.n.o.s..6.2. - [i4 t3.el 1100 {tris) (Cil £t} <br /> UN 3291,PG It Cu Ft. <br /> evlkillwaste ( z -"� <br /> Cu Ft. <br /> I 3.Generator's Cer-Iftetlon:"I hereby declare that the contents of this consignment are fully and accurately TOTA ® Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and IabeNedrplacarded,and <br /> are in all respects in proper condition for transport according io applie-we <br /> eiinternational and national gover n ragutations' <br /> I - �Printedrrypad Name W�n�y MOWW`�� Signature Data_E:,22 <br /> 2 <br /> 4.TRANSPORTER 1 ADDRESS: Phones: (916) 985 - 5606 <br /> w STE72ICSCLE Applicable Permit Numbers: <br /> 11875 white ]Iaack RLI; <br /> a ® This in a� Through Shipment <br /> I Rancho Cordova,CA 9574-17 <br /> ICE a TRANSPORTER CERTIFICATION:Receipt I medical waste as described above. <br /> j PrinUType Name Signature F Date �� l <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS Phone a: <br /> 1 Applicable Permit Numbers. <br /> I Lu <br /> Lu <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> - PrinMpe Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone M <br /> IS Applicable Permit Numbers: <br /> $ iNTE:RMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> a�z <br /> - Print/Typo Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transferred ` earda alis, W Q to : Nath SA lake,UT <br /> A.Designated Facility: E1111111.Alternate Facility: MAC.Attemate Faaifity: IIAD.Attemate Facility: <br /> SI6RICYCLE.I ST'ERICYCLE.INC. STERiCYCLE,INC, SYMCYCLE,INC. <br /> 1 MIN Ooodmft r,,:svlisft AW1 M 90 North t i W t+" 1613 St81t or <br /> San LeandmAA CA st3722 North SO LNaa.LST <br /> VUbe CRir,CA I <br /> I <br /> (510)50-1781 (559)W. <br /> -OW (801)936-1555 ism 720-0170 <br /> 1531.TSK)SM 839)1361X1.S ._.. 22 CkM V Indneiraft P-S,PL115 <br /> 9t-02 <br /> a TREATMENT FAM0446192AN11904en authorized by the appllcable state agency to accept untreated medical wastes and that I have <br /> r received the above indicated wastes in accordance with the requirement outlined in that authorization. <br /> PrintiType,Name .r I t Signature Dais <br /> i <br /> 000 7 9-2 <br /> s <br /> ORIGiNAL Mf�e � �21l09 <br />