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..._____. f f!2GgJ�3UOuJHI�•i.i•r�.,-..........
<br /> MEDICAL WASTE TRACK�NG FORNt NUMBER
<br /> ®i 1� Stericycle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1.800.234.0051 STANDARD MANIFEST 001•10•06•STD
<br /> �6 rroU14n1 Yroyte.reduM,@aAw'
<br /> Route #: 913 '3 IMC0087411
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ATTNi Ann
<br /> HRgr,}Ct CONVALESCENT HOSPITAL
<br /> 900 NORTH CHURCH STREET
<br /> LODI. CA 95240
<br /> I !7nc11 q-1::o`- !
<br /> CUSTOMER NumeER ,1 A 1 I, C-Art t GENERATOR'S REMSTRAVION N
<br /> 1 2A.DESCRIPTION OFWASTE Z8, CONTAINER TYPE 2C. NO.OF 20. VOLUME
<br /> I REGULATED MEDICAL WASTE,A.o.C.6.2, CONTAINERS
<br /> I UN 3291,PG 11 3.4-(Bic)>, TP14-(Path) 44 Gal Tub (5,9 Cu ft) Cu Ft,
<br /> REGULATED MEDICAL WASTE,rl.o.s.,6.2,
<br /> UN 3291,PG 11 RB21-(Bic) / TB1S-(Path) / TYIS-(Chemo) 20 Gal Tub (2.7 Cu Ft.
<br /> REGULATED MEDICAL WASTE.n.o.s.,6.2,
<br /> CC T549-(Bio) / TF49-(Path) / TY49-(Chemo) 57 Gal Tut: (4.9
<br /> O UN 3291.PG II Cu FL
<br /> 4 REGULATED MEDICAL WASTE.n.o.s.,6.2, TB3S - 26 Gal Tub (Bio) (3.5 Cu ft)
<br /> UN 3291,PG 11 Cu Ft.
<br /> W REGULATED MEDICAL WASTE,A o.s.,6.2,
<br /> W. UN 3291,PG It TBS7 - 90 Gal Tub (Bio) (12 cu ft) Cu Ft.
<br /> UREGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> UN 3291,PG 11 TB64 - 48 Gal Tub (Bio) 6.4 cu ft) Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s..6.2,
<br /> UN 3291,PG 11 "Tog 2a n ♦ ; e a c. Cu Ft.
<br /> REGULATED MEDICAL WASTE,11,01.5.2,
<br /> UN 3291.PG II 3T64 - 64 Gal Tub (Biel (9.67 au ft) Cu FL
<br /> phaarmaceotleal waste
<br /> ( Cu Ft.
<br /> 3,Generator's Certification.I hereby declare that the contents of this consignment are Sully and accurately T®YACs ® �f •� Cu Ft.
<br /> described above by the proper shipping name,and are classified,packaged,marked and fabelleftlacarded,and
<br /> are in all respects In proper conditiwt for transport according to applicable International and national governmental regulations'
<br /> I
<br /> 1 IPrintedlTyped Nama �
<br /> X signature � Date 1
<br /> 4.TRANSPORTER t ADDRESS: V w Phone N:
<br /> ApplkWble't'ermil Umbers:55 0 CZ
<br /> 11875 White Rack Rd
<br /> <C0 This is a Through 3hipmert
<br /> g 5TERICYCL£
<br /> n� TRANSPORTER FT-AT30 rjeeaipt o�snedat waste as described above.Lai e // �Q
<br /> Print/Type Name Signature Date_(J -�
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: V Phone a:
<br /> a Applicable Permit Numbers:
<br /> cc
<br /> I INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> M 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone N:
<br /> I) a Applicable Permit Numbers:
<br /> m INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> � a
<br /> �
<br /> Print/Type Name Signature Date
<br /> 7,DISCREPANCY INDICATION
<br /> Transferred containers. cu f4 to : (`forth Salt lake UT
<br /> 8A.Designated Facility: 86.Alternate Facility: 8C.Alternate Facility. ❑80.Altonlata Facility:
<br /> STERICYCLE.INC. STERICYCLE.INC. STERICYCLE INC. Sl CRIC'YCLE.INC.
<br /> uQ 1345 Doolittle Drive.Suite C 4135 W.Swift Avenue 90 North 11i!(l�+Vek 1612 Starr Dr
<br /> �. San Leandro.CA 94577 Fresno.CA 03722 North Salt Lake.LIT 840554 Yuba City,CA 96991
<br /> (5413)5ft2-17$1 (5691 275-0994 (8Q1)938-i555 (53R)790- 4
<br /> 074
<br /> TS31.TS10aT25 7S OE 22 �t:a=aVtnc�necatiav, t�@1TT4*�9t F-i3,F-tt5
<br /> oil
<br /> TREATMENT FACILITY:I Itify that 1 have been authorized by the applicable to ag accept untreated medical wastes and that i have 1
<br /> F- received the above in ed St s in accordance with the requirernlM, Zint �ut#fclri anon.
<br /> �o/� � r1. r, F�� ;2ter._ NOV 0 9 2009
<br /> Pdntr ypo Name Signature Date
<br /> I
<br /> 000107
<br /> ORIGINAL.
<br />
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