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MEDICAL WASTE TIMKIN O"NUME)E R <br /> ®lSteri cle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-BOa234A051 STANDARD MANIFEST 001.10.0e-STD <br /> e"® �°""�° R " Route #: 413 k unnt-nC17(!t'T <br /> i.Generator's Name,Address and Telephone Number <br /> AM: AnnI S I X11 I I S �1 i ISI I Il I l Isnail �I <br /> I ARBOR CONVALESCENT HOSPITAL <br /> 900 NORTR CHURCH STWMT <br /> LODI, CA 95240 <br /> (209) 333-1222 8/21/2001 <br /> CWTOMER Nmitrm _ GERVIAIUR'8 REUMMAnoN rt { <br /> 2A.DESCRIPTION OF WASTE 2a. CONTAINER TYPE 2C.NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2. CONT ERS <br /> UN 3291,PG II 1!- H ) TP14-(Path.) 44 Sal Tub (5,9 ata ft) Cu Ft. <br /> REGULATED MEDICAL WASTE, <br /> UM3291,PG1I TBryl-(Biu) / TB15-(Path) 17Y15-(C11emo) :70 tial Tub (2.7) Cu FL <br /> REGULA0 ON3291TEDMEDtCAIwASTE,n.o.s.,6.2, TB49-(Biu) / TV49-(Bath) / 7Y49-(Cbemst) 37 Gal Tub (4.9) <br /> Q ON 3291.PG!I Cu Ft. <br /> I 4 REGULATED MEDICAL WASTE.n.os..6.2, T835 - 26 Gal Tub (Bio) (3.5 cu ft) <br /> UN 3291,PG ii Cu Ft. <br /> i W REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> W UM 3291.PG II T851 - 90 Gal Tub (Bio) (12 Cu ft) Cu Ft. <br /> Q REGULATED MEDICAL WASTE,n.os.,6.2, <br /> UN 3291,PG It TB64 - 48 Gal Tub (Rio) (6.4 au ft) Cu Ft. <br /> i REGULATED MEDICAL WASTE,mo.s.,6.2, <br /> UN 3291,PG II Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o,s.,6.2, <br /> UN3291.PGII ST64 - 64 Gal Tub (Si.o) (9.67 cu ft) (u Fl <br /> pharmaceutical W951e <br /> r7-.7' <br /> 7� Cu t. <br /> 3.Generators TOTALS Certification:-1 hereby declare that the contents of this consignment are fully and accurately ® I (a Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and <br /> are in all respects in proper condition for transport according to applicable international and national governmental reguiatfms' Q <br /> X1113rinted(Tyr Signature Dal. <br /> 4.TRANSPORT IADDRESS: Phone R: (926) 98.5 - 5• <br /> O STERICYCLE Applicable Permit Numbers: <br /> 11875 White Rank Rd <br /> This is a Through "chi A1ent <br /> Rancho Cordova,CA 95742 10 1 <br /> CL 0Z TRAN PORTER CERTIFIGA N.Receipt of medical waste as described above. <br /> ~ <br /> print/Ty o Name -Signature Date <br /> a 5.INTE MEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone M: <br /> ¢ Applicable Permit Numbers: <br /> I <br /> INTER DIATE HANDIER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described I <br /> t <br /> PrintRypa a Signature Date <br /> 6.INTERME\ATEANDLER 3/TRANSPORTER3 ADDRESS: Phone 4: <br /> $¢ Applicable Petrnit Numbers:0.51INTERMEHANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Printrrype NSignature Date <br /> 7.DISCREPANCY IN (CATION <br /> Transferred containers cu R to: North Sats lakel UT <br /> } 8A.Designated Fad( all.Alternate Faclifry: 8C.Anemats Facility: Sb.Anemate Facility: <br /> C STERICYctE,INC. STERICYCLE.INC. STERICYCLE,INC. <br /> a $ A e ute C 4135 W.SWR Avenue 90 taint 1100 West 1612 Starr Or <br /> u <br /> an Loan CA 946 7 Fresno,CA 513722 North$0 Lake.UT 840 Yuba�Y.CA 3'5991 <br /> H (510)562- 1781 (559)276-0994 (801)936.Ism (530)790-0170 <br /> TS31. MST25 TSIOST 22 Class Y Incineration P-61 P-115 <br /> Permit#81.02 <br /> pc Pit TREATMENT>FACIt.rTY•�I certify Etat I have been authorized by the appli estate agency untreated medical wastes and that t have I <br /> t- received the above Indicated wastes in accordancee with the requirement utlined in that cut rizat' <br /> Pruttffjpa Name ` (i 14-0 � �"` Signature Data I <br /> Q� 7.4GpE�'G'�R I <br /> ORIGINAL <br />