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MEDICAL.WASTE TRACKING FORMt UMDER
<br /> s e• Stericycte' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800-234-0051 STANDARD MANIFEST 0011-10-06-STI)•• n.P_oo r. 6 A.dud,y Ank: Route 4: 413 2
<br /> h1I)RC007M5M
<br /> 1 1.Generator's IVarate,Address and Telephone Number
<br /> IATPN: Ann
<br /> ARBOR CONVALESCENT HOSPITAL
<br /> 940 NORTH CHURCH STREET
<br /> LOUT, CA 95240
<br /> 209 333-1222 7/3/2005
<br /> CusTomon NUAtaER _nniGENERATOR's REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 26. CONTAINER TYPE 2C. NO.OF 20, VOLUME
<br /> REGULATED MEDICAL WASTE,n.o.s-5.2, CONTgINERS
<br /> UN 3291.PG If TB14-(113.0)j TP14-(Patti~) 44 Gal "Tub (5.9 act tt:)
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, T821-(Bier) / T1115-(Path) / TY15-(Chemo) 20 Gal Tub 42.7
<br /> UN 3291.PG II Cu FI,
<br /> REGULAUN 291,PIED G
<br /> WASTE,n.o.s.6.2, TB49-(Bio) / TP49-(Path) ! TY49-(Cheno) 37 Gal Tub (4.9
<br /> Q Cu FL
<br /> f— REGULATED MEDICAL WASTE,a.o.s.,6.2,
<br /> CC UN 3291,PG 11 T835 - 26 Gal Tub (Bio) (3.S cu It) Ca Ft.
<br /> W REGULATED MEDICAL WASTE,n.o.s..6.2,
<br /> W UN 291,PG it TB57 - 94 Gal Tub (bio) (l.2 Cit tt)
<br /> ( Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> UN 3291,PG II TB64 - 48 tial, Tub vii 6.4 cu ft Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> UN 3291,PG 11 Cu Ft.
<br /> REGULATED MEDICAL WASTE,n,o.s.,6.2,
<br /> LIN 3291,PG 11 ST64 - 64 Gal Tub (Bio) (cu It) Cu R.
<br /> Phafmaceigical Waste
<br /> Cu
<br /> 3.Generator's Certification:"I hereby declare that the contents o1 this consignment are fully and accurately TOTALS I/' ! Cu ft
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelledlplacarded,and
<br /> `are inall respects in proper condition for transppo-rttaacclorditngg toapplicabblle International and national governmental regulations."
<br /> 4 �e
<br /> f - I Printedfr ed Name '7�N�`� t H / T�t/"�. Signature Date -7 rs 'y 1
<br /> 4.TRANSPORTER 1 ADDRESS: Phone I: (916) 98.5 — S.
<br /> �u
<br /> STERICYCLE Applicable Permit Numbers:
<br /> p 11875 fdhite Rock Rd
<br /> IL Rancho Cardsrva,CA 95742r ? ® This is a Through shipment:
<br /> 2
<br /> a q TRANSPORTER ERTIF=TION: eceipt of medical waste as desctd ftve.
<br /> PdnVTypeNama Sfgnature Date .3:
<br /> 5.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone If.
<br /> 1'15 Applicable Permit Numbers:
<br /> I INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> a.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone tt:
<br /> Applicable Permit Numbers:
<br /> 3 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> s PrinUType Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Transferred gantalners, cu ft 1o : Mcgh Salt lake.UT
<br /> SA.Designated FeWity: e9.Alternate FacURy: LJ BC.Alternate Facltity: LID.Altamate Facility:
<br /> STERICYCLE.INC. STERICYCLE,INC. STERICYCLE,INC. STERICYCLE,INC.
<br /> 1345 Doolittle Drive,Suite C 4135 W.SvM Avenue 90 North t 10D West 1612 Starr Dr
<br /> San Laandro.CA 94577 Fresno,CA 93722 Nordt Salt Lake.UT 84054 Yuba City,CA 95991
<br /> (510)662. 1781 (559)2T5-0994 (801)936- 1555 (530)790.0170
<br /> LU
<br /> 7531,TSfOST25 IWOST 22 Class V In+dneradon P-8,P-1 is
<br /> 11 1t- Pen"W 91-02
<br /> TREATMENT FACILITY:I Certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the above Indicated wastes in accordance with the requirement outlined in thotlauthorization.
<br /> Prhtrfype Signature D e -�� V'�s`
<br /> JUL a 7 2009
<br /> ORIGINAL
<br />
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