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_ _. _ _._ .._- ---__ ' tdEotCAL wASTE��L° l "' Rl4 �F�JMBER- <br /> •!®Y 5teritycle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1.800-234.0051 STANDARD MANIFEST 001.10-00-STD <br /> ®a® rretean,p RaPk.L,a..cuq Rb¢: <br /> Route .#: 413 -1 mnProna i(;P <br /> 1.Generator's Name,Address and Telephone Number !! ff (( } t <br /> ATTN: Ann <br /> ARBOR C014VALESCENT HOSPITAL <br /> 900 NORTH CHURCH STREET <br /> LODI. CA 95240 <br /> f909% 33 <br /> CUSTOMER NUMBER GaENERATOrt s REGISTRATION R <br /> 2A.DESCRIPTION OF coWrAINERTYPE 2C.NO.OF 201. VOLUME <br /> REGULATED MEDICAL WASTE,ri.os.,6.2, CONTAt <br /> UN 3291,PG II 0 TP14- ✓ Cu Ft. <br /> REGULATED MEDICAL WASTE,n.c.s.,6.2, _=__ <br /> LIN 3291,PG Ilr - <br /> 5. =0 29 0al liah f Cu Ft. <br /> pC REGULATED MEDICAL WASTE,n.0.s.,6.2, <br /> p UN 3291,PG if TB49- Biot TP49- Path TY49-(Che-ao) 37 Gal Tub f4.9 Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG 11 TB35 - 26 Gal Tub (Bio) (3.5 cu 1:t) Cu Ft. <br /> W REGULATED MEDICAL WASTE,It.o.s.,62, <br /> W UN 3291,PG it TB57 - 90 Gal Tub (Bio) 12 ru Et) Cu FL <br /> p REGULATED MEDICAL WASTE,n.o.s..6.2. <br /> UN 3291,PG II _ 'l m Cu Ft. <br /> 1 REGULATED MEDICAL WASTE,n.0.9,6,2, <br /> UN 3291,PG 11 Cu Ft. <br /> REGULATED MEDICAL WASTE,n o.s..6.2. " t Tub (ft." ` ` <br /> UN 3291,PG 11 22 f,17 Cu Ft. <br /> Pharmaceutical Waste ym Z 2 647 <br /> Ft <br /> 3.Generator's Certification:1 hereby declare that the conionts of this consignment are fully end accurately TATA!-R t" Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and labe8ed1placarded,and <br /> are in all respects In proper condition for transport according to applicable intematlonal and national governmental regulations" <br /> IINIPrintedfryped Nemo e-�Q,n�.,--_dio.- Signature �d•r '"'fes"` Date <br /> 4.TRANSPORTER 1 ADDRESS; Phone tt: <br /> Appllc661a.Wm41&lhbers:55 0 6 <br /> 11875 White mock Rd <br /> ZTERICYCLE Thiz i= a Through Shipment <br /> a.szt TRANSPORTi� IIF 11 ��waste as described above. J /� <br /> PdnVTVpe Name Signature Rate Y J <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER2ADDRESS: V Phone 0: <br /> Applicable Permit Numbers: <br /> I <br /> INTERMEDIATE HANDLER t TRANSPORTER CERTIFICATION:Recut of medical waste as described above. <br /> Print rrypa Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: PhoneIx a: <br /> Applicable Permit Numbers: <br /> i INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> & ac r 3•5 .-r-ij ff fn- Niarth P.: IL <br /> A.10es19nated Facility: BILArte—ff wW Facility: 6C.Alienate Facility. 80.Alternate Facility: <br /> STERICYCLE.INC. STERICYCLI_.INC. STERICYCLE.INC. STERICYCLE,INC, <br /> 1345 Doolittle Drive.Suite C 4135 W.Svrift Avenue 90 North 1100 West 1812 Starr Dr <br /> San Leandro.CA 94577 Fresno.CA 93722 North Salt Lake,UT 84054 Yuba City,CA 95991 <br /> (510)562-1761 1`559)215-0994 (601)938.1655 (530)790-0170 <br /> T531,TSfrJSTZ t TUOST 22 Class V lntxneratior, Penvitg 91 i P-6,P-115 <br /> �C TREATMENT FACILITY:I certity that i have been authorized by the applicable state agenoyAo accept untreated medical wastes and that 1 have <br /> h received the above indicated wastes in accordance with the requireme�Oul� in tha rization. OCT <br /> 09 <br /> Pdntrrype Name r Signature Date 0 4 1 V �� <br /> e <br /> JQC# 7 6 <br /> I <br /> ORlt"s1PlAL <br />