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- MERICAL WASTETWh&QW#tb4(h+1UMBER <br /> s® stericycte' IN CASE OF EMERGENCY CONTACT:CHEMYREC#-800-2340051 STANDARD MANIFEST 001-10-06-STI) <br /> e4 rM�ninR Mpde.Reda(Lg RML' <br /> 1.Generator's Name,Address and Telephone Number <br /> &TTN-. hnn IN I list I <br /> till <br /> VWOR COWALESCENT HOSPITAL <br /> 900 NORTH CHURCH SMET <br /> LODI, CA 95240 <br /> n ~ .- - <br /> CUSTOMER NuaeER mrig yws ReGtSTRA=N fI <br /> 2A.DESCRIPTION OF CONTAINER TYPE 2C.NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,O.o.s.,6.2, CONTAINERS <br /> UN 3291.PG It Cu A. { <br /> J REGULATED MEDICAL WASTE,n.o.s.,6 2, <br /> UN 3291,PG 11 9 Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s..6.2, <br /> Q UN 3291,PG If m Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, 1101 <br /> j�Q <br /> a: UN 3291,PG 11 t t [- Cu Ft. <br /> Ul REGULATED MEDICAL WASTE,II.O.s.A2, <br /> W UN 3291,PG It1- !rubfit) Cv Ft. <br /> Ur REGULATED MEDICAL WASTE,R.as.,62, <br /> UN 3281,PG 11 Cu FL <br /> REGULATED MEDICAL WASTE,0.0.&,&2, <br /> UN 3291,PG II Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.S.A2, ST96 - 96 Gal Tub (Bio) (17.78 cu ft) I <br /> UN 3291,PG 11 Cu Ft. <br /> Cu F1 <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 ossified.packaged,marked and fabeil"placarded,and <br /> are In all respects In proper condition for transport according to applicable International and national governmental <br /> l°"�'rre/guullatione <br /> ( <br /> 14 1 PrintedtTyped Name Signaturo F°"` Date _L._ <br /> tc 4.TRANSPORTER 1 ADDRESS: Phone 4: l <br /> du Applicable t�rlTriMum�& _ 5• i <br /> ST£RICYCLE <br /> 13875 White Rock Rd <br /> R1C 2g 9 9a This im a Through Shipment <br /> a, TRANSPORT&(!EP` l-[AA; RFf'lesCllpt P,.7F.1wasteesdescribed <br /> FE Pdnt/type Name Signature Date 9-N <br /> Mel <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone 8: <br /> d" Applicable Permit Numbers: <br /> Q <br /> INTERMEDIATE:HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PdnUtype Name _Signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 4: <br /> Applicable Permit Numbers: <br /> RV <br /> V INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above, <br /> PrinMpe Name Signature Date <br /> T.DISCREPANCY INDICATION <br /> 9 <br /> ❑8A,Deelgnated Faciltty: Ntenmto A mble astake80.Altmrtate Facility: <br /> u STr-RIrV('l F INC: STE:RICYCLE,INC. STERICYCLE.INC, STERICYCLE,INC. <br /> LL il 345 i3oalhslo Drive,Suite C 4125 W.Swift Avenue 90 North 1100 West 1612 Starr Dr <br /> a- San Leandro,CA 94577F tdlnrth SaR 1 akA 11T IAAA,94 Yuba Circ.CA 1AW <br /> z (510)562-1784 (801)9313. 1555 (5301 780-04 70 <br /> j TS31.TSIOST25 OST 22 Class V Incineration P-d,P-115 <br /> }�4 Q Parsrit.� P1417 <br /> TREATMENT FACILITY:I certify th dti"aut zed by the a6plicable state agency to accept untreated medical wastes and that I have <br /> received the above Indicated waste in accordancettt�rgquirement outlined in that authorization. <br /> 0v1t$Sx� <br /> / <br /> PrinUType Nameu Data <br /> +V VV4 .� ar <br /> ORIGINAL <br />