Laserfiche WebLink
MEDICAL WASTE f` 1 i► r A 7GMSER <br /> O s®O Sterieycle- IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800-234.OD51 STANDARD MANIFEST 001.10•9&STD <br /> MO PmlMini MpN.Rrd,anp%d: <br /> 1.Generator's Name,Address and Telephone Number ffRif + <br /> ATTN: Ann <br /> ARBOR CONVALESCENT HOSPITAL <br /> 900 NORTH CHURCH STREET <br /> LODI• CA 95240 <br /> CuSTomER Numarn ^ GmrRxrows REMSTRAnoN# <br /> 2A.DESCRIPTION OF VA!ftt At. CONTAINER TYPE 2C.NO.OF 2D. VOLUME <br /> REGULATED MEDICAL WASTE,mo.s.,62, CONTAINERS <br /> UN 3291,PG 11 _ Cu Ft. <br /> REGULATED MEDICAL WASTE.n.o.s.,6.2, <br /> UN 3291,PG 11 — (z*al Tuh f2 Cu Ft. <br /> ( REGULATED MEDICAL WASTE.n,o.s.,6.2, <br /> O UN 3291,PG Ii TB49— Bio TP49— Path TY49— Chemo 37 Gal Tub 4.9 Cu Ft. <br /> 4 REGULATED MEDICAL WASTE,n.o.s.,6.2.p� )UN 3291,PG 11 TB35 — 26 Gal Tub (Bao) (3.5 cu it <br /> Cu Ft. <br /> W REGULATED MEDICAL WASTE,na s.,6.2, <br /> W UN 3291,PG II TB57 1;0 Gal Tub Bin 12 cu #t) Cu Ft. <br /> REGULATED MEDICAL WASTE, <br /> UN 3291,PG II Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o,s.,6.2, <br /> UN 3291,PG ItF!. <br /> REGULATED MEDICAL WASTE,n.e.s.,6.2, <br /> UN 3291,PG 11 'k Cu Ft. <br /> Pharmaceutical Waste <br /> Cu Fi. <br /> 3.Generator's Certification:`i hereby declare that the contents of this consignment are fully and accurately T®TAI— Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and tabeiledfptacarded,and <br /> are in all respects In proper condition for rmsport according to applicable international and national governmental r gu ions" <br /> IV fPrintedllyped Name � Signature <br /> re Datet 6q4.TRANSPORTER 1 ADDRESS: Phone B: <br /> > AppikAW.0mlaUnbets:8546 <br /> 11675 White !tock Rd <br /> STERICYCLE <br /> Thia im a Through Shipment <br /> a�a TRANSPORT Fe R11 I R qTl waste as described above. <br /> ~ Q _q <br /> Printfrype Name Signature Dale <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone M <br /> N <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> e.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#: <br /> se <br /> � Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> • t <br /> -COCI? $A,Deelgnated Facility: as.t�Facilaty: 11C.ABernate Facility: BD.Alternate Facility: <br /> o SIERICYCI P.INC. STERICYCLE,INC. STER{CYCLE INCSTERICYCLE,INC. <br /> u4. It 1 <br /> 345 Doolittle Drive,Suite C 4135 W.Swift Avenue 90 North 1100 West' 16 12 Starr Dr <br /> Be San Leantlro.CA 94577 Fresno.CA 99722 North Salt Lake UT 84054 Yuba Cly CA 95991 <br /> (510)582-1781 (559)275-0994 (801)938-1665 (530)790-0170 <br /> TS31.TS(OST25 TUGST 22 Glass/Inanetatiot% i'erwi�li B4 P-6,P-145 <br /> w TREATMENT�F�ACI %l fy that I have been authorized by the applicable state age to accept untreated medical wastes and that t have <br /> received tht rtes in acxardance with the requirement ed in thorizatlon, <br /> 22, <br /> Print/rype Name SignatureDate __SEP 2 9 2009 <br /> (3(3 Q 8 8 A <br /> ORIGINAL <br />