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MEDICAL WASTE�1Rf� fNG F{SRM NUMBER <br /> A+s A Stericycle* IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800-234.0051 STANDARD MANIFEST 001-10.66-STD <br /> • NDRICY F <br /> 1.Generator's Name,Address and Telephone Number - <br /> A,TT14: Ann <br /> ARBOR COUVALESCENT H03PITAL <br /> goo NORTH CHURCH STREET <br /> LODI, CA 95240 <br /> tf'ngl <br /> i <br /> { CUSTOMER NUMBER GENERATOR'S RERISTRATiON# <br /> 2A.DESCRIPTION OF •1- t CONTAtNERTYPE 2C.NO.OF 20. VOLUME <br /> f REGULATED MEDICAL WASTE,n.ri s.,62, CONTAINERS <br /> ON 3291,PG If ::':t� 14 '1 _ Cu FL <br /> REGULATED MEDICAL WASTE,n.o-s..6. <br /> LIN 3291,PG II _rfti S-rr ..Tti 2n all (2 71 Cu Ft. <br /> j pC REGULATED MEDICAL WASTE, <br /> p ON 3291,PG 11 40_4R,. r 1 P4a-r + 'k r q_/r N 07 1.21 Tlik 14 Q% Cu Ft. <br /> I Q REGULATED MEDICAL WASTE,rws.,6.2, <br /> I LUON 3291.PG 11 TE35 - 26 Gal 'Pub (Iiia) (3.5 cu ft) Cu Ft. <br /> REGULATED MEDICAL WASTE,n,o.s.,6.2, <br /> W ON 3291,PG 11 rr - an - ) r — 44-1 Cu Ft. <br /> VI REGULATED MEDICAL WASTE, <br /> ON 3291.PG II <br /> Cu F!, <br /> REGULATED MEDICAL WASTE, » '- " <br /> ON 3291,PG 11 <br /> REGULATED MEDICAL WASTE.n.o.s.,6.2, _ a (lo) cru Cu Ft. <br /> I <br /> ON 3231,PG If Cu Ft j <br /> aff- _ _ I <br /> Pharmaceutical Waste Cy Ft. <br /> 3.Generator's CenfNcatlon:'I hereby declare(hat the contents of this consignment are fully and accuratelyT®TALS ® 3r 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 regulations" <br /> Q <br /> - Printed/T d Name l r�C 9 rJut Signature Date r'l <br /> 4.TRANSPORTER t ADDRESS: Phone 0, qft, <br /> W STERICYCLE Applicable PG eTrt11l�umt5ers� _ S' <br /> 11875 White Rock Rd (� Thim is a Through Shipment <br /> aM t2 }� CA 957,4 t.n. t <br /> TRANSPORH(;LHIF(; N:Receipt of medical waste as described a ,,��y} <br /> t" <br /> Print/Type Name Signature Date . <br /> I S.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: V Phone#: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described alae. <br /> PdnV ype Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS. Phone#: <br /> a Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> r � <br /> PnnllType Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> 8A.Designated FedUly: 016B.Almatate F II 8C.Aitsmata Facility:- - 8D.AltemaN Facility: <br /> A-MRICYCI F INC: STERICYCLE,fNG. STEt�tCYrLE.INC. STERICYCLE,INC. <br /> 1345 Doolittle D&e,Suite C 4135 W.St'v*Avenue 90 Narth 1 tDO West 1612 Starr Dr <br /> San LezndTo,CA 94577 Fresm.CA 93722 tctnrth RaLt1-41cp 1)'T PAIVU Yuba City.CA 96991 <br /> (510)582-1781 (559)275-13994 (601)936-1555 (5301 790-0170 <br /> UJJ g TS31.TSIOST25 TS/OST 22 Class V Incineration P-0,P-115 <br /> TREATMENT FACILITY' er' hat I have been authorized by the applicable ate ag o accept untreated medical wastes and that I have <br /> received the ab icated es in accordance with the requirem ed int orizatlon, ��P 2U9 <br /> { 15 u <br /> Printlrype Name Signature Date <br /> ORIGINAL <br />