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MEDICAL WASTE TRACKING FORM NUMBER <br /> w®® Stericycle' IN CASE OF EMERGENCY CONTACT:CNEMTREC 1-SM234.0051 STANDARD MANIFEST WI•10-WSTO <br /> •• .R . : Route ft: 413 3 MDRC007KIIE <br /> 1.Generator's Name,Address anclTelephone Number <br /> A M: Ann <br /> I ARBOR CONVALESCENT HOSPITAL <br /> 900 NORTH CHURCH S MET I <br /> LODI, CA 95240 <br /> (209) 333-1222 6/19/2005 <br /> I <br /> CusTomEnNuhreEn 6041015-001 GFAtERATon'SREGISTRATIONO <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C.NO.OF 20. VOLUME 1 <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, ga.(Bi / TPU-(Path) 44 OWL Tub (S.9 ou !t) CONTAINERS t <br /> I UN 3291,PG It r Cu Ft. <br /> I REGULATED MEDICAL WASTE.n,o.s•,6.2, -(B10) / T815-(Fath) / 7Yl5-(Chemo) 20 Gal Tub J,7} <br /> UN 3291,PG 11 Cu Ft. <br /> REGULATED MEDICAL WASTE.n.o.s.,6.2, T1349-(Bin) I TP49-(Path) / TY49-(Cheat*) 37 Gal Tub 0. <br /> iJ Q UN 3291,PG tt Cu Ft. <br /> Q REGULATED MEDICAL WASTE.0.0-s-.6-2Ir , <br /> TB3 - b Gal TtJ3A {gyp (3.5 au ft} <br /> UN 3291,PG II Cu Ft. <br /> W REGULATED MEDICAL WASTE,n.o.s.,6.2, T857 - 90 Gal Tub (Bio) (12 cu tt:) <br /> I 2 UN 3291,PG it Cu F1. <br /> ILI <br /> REGULATED MEDICAL WASTE,n.os.,62, <br /> I UN 3291,PG U Tg64 - 453 tial Tub (Bio) (1i.d cu ft) Cu Fl. <br /> REGULATED MEDICAL WASTE,n,o,s.,6,2, <br /> UN 3291,PG II l3T96 - 96 Gal Tub (Bio) (cu ft) Cu R. <br /> REGULATED MEDICAL WASTE.n.O.s..6.2, gT64 - $4 Gal Tub (Bio) (cu ft) <br /> UN 3291.PG II Cu Ft. <br /> Pharmaceutical Wage / u Ft. <br /> ' 3.Generator's Certification:'I 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 Isbell carded and <br /> are in an respects fn proper condition tar transport according to applicable iruamational and national 9 rnmental reguIs ions' / / <br /> i - il- fG <br /> ' I ^ IPNntedlt dName Signatu to <br /> i 4.TRANSPORTER 1 ADDRESS:�TE"RICYCIaE Phone M: (916) 985 - S. <br /> Applicable Permit Numbers: <br /> l 11876 White Rack Rd0 <br /> t� This is a Theouglh Shipment <br /> 0. Rancho CordovaACA 9579'2 U <br /> ZTRANSPORTER CERTiFICATI :ASC04 t Of medical waste as described e. <br /> Print/fype Name Signature Date <br /> S.INTERMEDIATE HANDIER 2/TRANSPORTER 2 ADDRESS: Phone A: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt or mewl waste as described above. <br /> Print/titpe Name Signature Date <br /> M 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone a: <br /> Applicable Permit Numbers: <br /> jINTERMEDIATE HANDLER ITRANSPORTER CERTIFICATION-Receipt of medical waste as described above. <br /> °l2 x <br /> a Print/Type Name Signature Date <br /> T.DISCREPANCY INDICATION <br /> Transferred containers, cit it to : North Sail take,UT <br /> SA,Designated Faditly: 0 60.Alternate Facility: U SC.Altemate Feci ty: aD.Alternate Facllity: <br /> STE MCYCLE.INC. S'TERICYCLE,INC. SMPJCYCLE,INC. STERICYCLE,INC. <br /> Q 1345 Ooo=o Drive,Sub C 4135 W.SWR Avenue 90 North 1100 V*5t 1612 SUIT Or <br /> [ Q Yuba Ctty.CA 95991 <br /> San lsaftdro,CA 94577 Fresno,CA 93722 North Salt Lake.UT 84054 <br /> (510)$62-1781 (659)275-0984 (8011)936- 1555 (530)790.4170 <br /> h TS31,TSIOST25 TSIOST 22 Ctass V I P-8,P-115 <br /> Pef rIPS 91.02 <br /> Pil TREATMENT FACIL : I lily that I have been authorized by the appl' le st noy to accept untreated medical wastes and that I have <br /> received the ndi wastes in accordance with the req outlin horization. <br /> Pr(ntrtypeNam o 7AZ&-0'f Signature of D to RECEIVED <br /> ; . JUN 2 4 2009 <br /> MEDICAL WASTE <br /> ORIGINAL i <br />