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MEDICAL WASTE io tKdF0Wb BER <br /> ®,a.*®4 Stericycle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1.600.234-0051 STANDARD MANIFEST 001.10.06-STD <br /> a wot�.tF,p►eogEe.f.6xh,p R.ht: �t t•�r�f^n e� [�t <br /> 1.Generator's Name,Address and Telephone Number <br /> A.TTN: Parsct <br /> ARBOR CONVRIX3CEINT HOSPITAL <br /> 900 NORTH CHURCH STREET <br /> LODT, CA 95240 <br /> 202) <br /> f c <br /> CUSTOMER NUMBER GeueRATOR's REarsTAA ri p <br /> 2A.DESCRIPTION OF CONTAINER TYPE 2C.NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, CONTAINERS <br /> UN 3291,PG N _ a Cu Ft. <br /> REGULATED MEDICAL WASTE,n.os.,6. , <br /> UN 3291,PG 11 _ - Cu Ft. <br /> E?» REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> Q UN 9291.PG 11 - _ q_ A Cu Ft. <br /> Q REGULATED it WASTE.n.o.s.,6.2, <br /> pC UN 329[,PG II TB3S - 26 Gaal Tub Bio) (3.S au ft) Cu Ft. <br /> W REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> W UN 3291.PG It TR57 90 t" Cu Ft. <br /> REGULATED MEDICAL WASTE,mo.s..6.2, <br /> UN 3291,PG II Cu Ft. <br /> REGULATED MEDICAL WASTE.n.o.s..62. _ <br /> UN 3291.PG If <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, Cu Ft <br /> UN 3291,PG 11 Cu Ft. <br /> Pharmaoeutica#Waste <br /> f 3.GeneraWs 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 labetlewplacarded,-- <br /> are in all respects in proper condition for transport according to applicable International and national governmental rogulations! <br /> X1 <br /> Name ZxonSignatureOQ&49� Date <br /> 4.TRANSPORTER 1 ADDRESS: Plane M: 4n q11 _ 5. <br /> STERICYCLE Applicable Per um els. <br /> O 11845 White Rock Rd <br /> V) ha a Cik 9574 `Thio i� `1RT�ough 5hipmeno <br /> a TRANSPORTS RTI A QCZA t of medical waste as described a �J <br /> _ PrinUType Name Signature Date •"j�S <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone v: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Racaipl of medical waste as described above. <br /> Prnt/Type Hama Signature Date• <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 4: <br /> S <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> �- Prnt/TypeNatne Signature Date <br /> 7.DISCREPANCY INDICATION <br /> A.Designated Facility. BB.IIT -"fe Fiscflfty: 8C.Alternate Facility: 81).Aaemats Facility. <br /> c;TF-RIrV(:I F INr. STERICYCLE,INC. STERICYCLE,INC. STERICYCLE,INC. <br /> 1345 De o#ittie Drive,Suite C 4135 W.Swift Avenue 80 North i 100 Mst 1 B12 Starr Or <br /> Sart t eandrD.CA 84577 Fmsno.CA 93322 <br /> hf nrttl Raft•1 alt 1 IT R41)TiA Yuba City.Ch 25995 <br /> (510)562-1781 (559)276-0994 (80f)938-1555 (5301790-0170 <br /> T53 1.TSIOST25 TSIOST 22 Class V Incineration P-0.P-115 <br /> „y PrM-t-04 Al-n7 <br /> U.1 TREATMENT FACILITY:I Certify that I have been authorized by the appli a sta ncy to accept untreated medical wastes and that I have <br /> received the above Indicate wastes In accordance with the require utline uthorization. 209 <br /> Prn*pe N L" - Signature Date <br /> 000272 <br /> ORIGINAL <br />