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y MEDICAL WASTE TRACKING FORM NUMSO
<br /> 4040 Stericycie' IN CASE OF EMERGENCY CONTACT:CHEMTREC i-SM2340051 STANDARD MANIFEST 001.104"G
<br /> °•• �'M'�rs. re" : Route #: 4.13 1 MDRC007JCX
<br /> 1.Generator's Name,Address and Telephone Number
<br /> AM: Ann Sao
<br /> ARBOR CONVALESCENT HOSPITAL
<br /> 900 NORTH CHT3RCR STREET
<br /> LODI, CA 95240
<br /> (209) 333-1222 6/12/2005
<br /> CUSTOMER NUMBER 6041015-001 GeIERATows REatsTRATton It
<br /> 2A.DESCRIPTION OF WASTE 2o. CONTAINER TYPE 2C.NO.OF 20. VOLUME
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, CONTA ERS
<br /> U -(H N 3291,PG II / '1rP14-(Path) 44 651 rub (5.9 Cit !t) i Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, TB21-(Bio) I T615-411?ath) / TY15-(Chemo) 20 Gal Tub (3.7)
<br /> UN 3291,PG 11 Cu Ft.
<br /> tr REGULATED MEDICAL WASTE,n.o.s.,6.2, T049-(Bio) / TP49-(Path) / TY49-4 Zt't emo) 37 Gal TUb (4.9
<br /> OUN 3291,PG 11 Cu Ft.
<br /> Q REGUtATEDMEDICAL WASTE,a.o.s.,6.2, T835 - 26 Gal Tub (Bio) (3.5 cu ft)
<br /> UN 3291,PG II Cu Ft.
<br /> W REGULATED MEDICAL WASTE,n.os.,6.2, TB57 - 90 Gal 'dub (Bio) (12 Cu ft)
<br /> tZ UN 3291,PG II Cu Ft.
<br /> REGULATED MEDICAL WASTE.mo.s.,6.2, T>T64 - 48 Gal Tub (Bio} (ls,d cu ftp
<br /> UN 3291.PG U Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s..6.2,
<br /> UN 3291,PG II ST96 - 96 Gal Tub (Bio) (Cu ft) CU Fl.
<br /> REGULATED MEDICAL WASTE,mo.s.,6.2, 8T64 - 64 Gal Tub (Bio) (cu ft)
<br /> UN 3291.PG 11 Cu Ft.
<br /> ftrin0C8trlival Wage
<br /> u Q.
<br /> 3.Generator's Certification:•1 hereby declare that the contents of this consignment are fully and accurately TOTALS` Cu Ft.
<br /> described above by the proper shipping name.and are classified,packaged,marked and labelled/ptacarded,and
<br /> aro in all respects in proper condition for transport according to applicable International and national govern ntal regulations"
<br /> e
<br /> PrintedlFyped Name "t `•" / i`Z � ''"Ti�'/�"' Si tkere_ Date
<br /> Cr 4.TRANSPORTER 1 ADDRESS: Phone e: (916) 985 - 5.
<br /> STERICYCLE Applicable Permit Numbers:
<br /> 11875 White Rook Rd
<br /> a O ® This is a Through Shipment
<br /> 2 CL Rancho Cordova,CA 95742
<br /> a q' TRANSPORTER Cf,.RTIFICATIO Receipt of medical waste as described above,
<br /> Print(type Name Signature 44-rd4 Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: V Phone N:
<br /> N
<br /> o a Applicable Permlt Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PMVrype Name Signature Date
<br /> 6,INTERMEDIATE HANDLER 3/TRANSPORTER 3ADDRE:SS: Phone 8:
<br /> 19
<br /> Cr Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Transtend containers, cu ft to: North Salt lake,UT
<br /> 8A.Designated Facility: 813.Aitemate facility: 8C.Alternate Facility: 80,Alternate Facility:
<br /> STERICYCL.E,INC. SIMICYCL.E,WC, STERICYCLE,INC. ST'ERICYCLE,INC.
<br /> a1945 Dooifitle Drive.Suite C 4135 W.SVWt Avenue 90 North 1100 West 1612 Starr Or
<br /> Fiji
<br /> San Leendm.CA 94577 Fresno,CA 93722 North Safi Lake.UT 84054 Yuba Clay,CA 95931
<br /> IT
<br /> U.
<br /> (510)562-1781 (558)275-0994 (NI)236-1855 (530)790-0170
<br /> W It TS31.TSIOST26 T5/OST 22 Class V indnetation P-61 P-115
<br /> PeMIW 91-02
<br /> Gc TREATMENT FACILITY:I certify that'l have been authorized by the applicable state agertcvs accept untreated medical wastes and that I have
<br /> t- received the above indica wris in accordance with the requirement ou in th t xatipn.
<br /> Print/Type Name Signature. Data
<br /> ORIGINAL.
<br />
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