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<br /> r • Steri cle' IN CASE OF EMERGENCY CONTACT;CHEMTREC 1.840.234-0051 STANDARD MANIFEST 001.10 STO
<br /> s.fi r„mwgrry.ere..M ria: Route #: 313 -2
<br /> _ MDRG0089V1
<br /> 1.Generator's Name,Address and Telephone Number f + N
<br /> ATTN: Ann � � � �� �� � � ��� 1 � 1� � 1# �
<br /> ARBOR CONVALESCENT HOSPITAL
<br /> 900 NORTH CHURCH STREET
<br /> LODI. CA 95240
<br /> 209 3331222 10 23 2009
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION it
<br /> WASTE-
<br /> 2A,DESCRIPTION OF 28_ CONTAINER TYPE 2C. NO.OF 20. VOLUME
<br /> REGULATED MEDICAL WASTE,mo.s.,6'2, I co INERS
<br /> 1 UN 3291,PG 11 TS1#-(3i Tpls-(Path) fs 611 Tub (S.9 c1, Ft) b Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.a.s.,6.2,
<br /> UN 3291,PG 11 T821-(Bio) / TB15-(Path) / 7Y15-(Chemo) 20 Gal Tub (2,7 Cu FI
<br /> REGULATED MEDICAL WASTE,n,o.s.,6.2,
<br /> Q UN 3291,PG II T549-(Bio) / TP49-(Lath) / 7Y#9-(Chemo) 37 Gal Tub 0.9 Cu Ft.
<br /> Q REGULATED MEDICAL WASTE,n,os.,6.2, TB35 - 26 Gal Tub (Bio) (3,5 au ft)
<br /> M UN 3291,PG It Cu Ft.
<br /> Ili REGULATED MEDICAL WASTE,nm.s.,6.2,
<br /> W UN 3291,PG 11 T557 - 90 Gal Tub (bio) (12 Cu £t) Cu Ft.
<br /> Vr REGULATED MEDICAL WASTE,n.0.s.,6.2,
<br /> UN 3291,PG 11 TE64 - 48 Gal Tub (Bio) 6.4 cu £t Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.os.,6.2,
<br /> UN 3291,PG N altGu FL
<br /> REGULATED MEDICAL WASTE,
<br /> UN 3291,PG II ST64 - 64 Gal Tub Bio (9.67 cu it Cu Ft.
<br /> Pharmaoeutical Waste Cu
<br /> t=t.
<br /> 3.Generator's Cerill fication:'I horaby declare that the contents o1 this consignment are fully and accurately TOTALS 11' Cu Ft
<br /> described above by the proper shipping name,and are classified,packaged,marked and tabelled/placarded,and
<br /> are In all respects in proper condition for transport according to applicable International and national govemmen re afions."
<br /> i, PiintodlTyped Name �^��-- Si nature Date LES-kj
<br /> 4.TRANSPORTER 1 ADDRESS: one f
<br /> �!ml - 550 !�
<br /> tM.bers:
<br /> aa 11875 White Rook Rd Ac PaYQ This is at Th u Shipment
<br /> N STERICYCLE
<br /> a TRANSPORT F t 1rt at{w/as(a as described a f �}
<br /> Print/rypo Name t SignatuTre pate "" `✓
<br /> 5.INTERMEDIATE trANDLER 2/TRANSPORTER 2 ADDRESS: Phone if:
<br /> wl� Applicable Permit Numbers:
<br /> R INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Prinitlype Name Signature Date
<br /> 8,INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> Q INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt or medical waste as described above.
<br /> zdx
<br /> PrinUrype Name Signature Date
<br /> .T.D CREPANCY INDICATION _____..-,_-__
<br /> Transferred containers cu It to : North Salt lake UT
<br /> } Ignated Facility: $8.Alternate Facility: ❑SC.Alternate Facility: 80.Altomate Feeilt .
<br /> Q STERICYCLE,INC. STERICYCLE,INC. STERICYCLE,INC, STERICYCLE,INC.
<br /> L, 1345 pooli L Drlva.5Ulte,C 4135 W.SWR Avenue 90 North 1100 West 1612 Starr Or
<br /> San Leandro.CA 94577 Fresno.CA 93722 North Salt lake,UT 84054 Yuba C' CA 95991
<br /> {51 0)562-1781 {659)275-0994 8011936-1555
<br /> TS3i'MOST25 TS(OST 22 Class►1 Moit>elatsan I'etTrit#g! (P 36Up79` 0170
<br /> TREATMENT FACILITY:I rtity that I have been authorized by the applicable state age accept untreated medical wastes and that I have
<br /> received the above t ed s in accordance with the requiremen In th rization,
<br /> W TNS � R � OCT 2 6 2009
<br /> Prinl/rype Name a Signature Date
<br /> ORIGINAL
<br /> _ - r,1l7F�u.n,cttrend 2r1.iSi
<br />
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