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- ~--ME®tCALWASTE TNAGKINGFORM NUMBER <br /> Nw®el! 5tericycle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1400.234-Mi STANDARD MANIFEST 001.10.08-STD <br /> ®s n,r.aeyhw..A,ax�•pun: Rotate #: 413 -1 MDRC€ 089YO <br /> 3.Generator's Name,Address and Telephone Number � { � 1 � � f � � � � ON <br /> 71TTAT• 1 lin <br /> {{ I( E{ <br /> ARBOR CONVALESCENT HOSPITAL <br /> 900 NORTH CHURCH STREET <br /> LODI. CA 95240 <br /> (209) 333-1222 11/20/2009 <br /> CUSTOMER NUMBER r,04 1 n _D0 I Gtktimmn s REWSTRAnoN 4 <br /> 2A.DESCRIPTION OF WASTE 26. CONTAINER TYPE 2C.NO.OF 2D. VOLUME <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, CONTAINERS <br /> UN 3291.PG It 14-($'o) 14-(Path) 44 Gal Tab (3.9 ca ft) Cu Ft. <br /> j REGULATED MEDICAL WASTE,n.o.s.,6. , <br /> UN 3291,PG II TB21-(Bio) / TB15-(Path) / TY1S-(Chemo) 20 Gal Tub (2.7 Cu Ft. <br /> (� REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> fO UN 3291,PG11 TB49-(Bio) / TP49-(Path) / TY49-(Chemo) 37 Gal Tub (4.8 Cu Ft. <br /> Q <br /> REGULATED MEMCALWASTE,n.o.s„6.2. TB35 - 26 Gal Tub (Bio) (3.5 au ft) <br /> UN 3291,PG Il Cu Ft. <br /> W REGULATED MEDICAL WASTE,0.0.s.,62, <br /> Z UN 3291,PG II T557 - 90 Gal Tub (Bio) (12 au ft) Cu Ft. <br /> Wr REGULATED MEDICAL WASTE,n.o.s.A2, <br /> UN 3291.PG Il TB64 - 46 Gal Tub (Bio) (6.4 au ft) Cu Ft. <br /> i REGULATED MEDICAL WASTE,n.o.s.,6.2. <br /> UN 3291.PG It IRMSSt Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2. <br /> UN 3291,PG fl ST64 - 64 Gal flub (Bic) (9.67 au ft) Cu Ft. <br /> Pharmaceutical Waste <br /> CuFt <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALSdescribed above by the proper shipping name,and are classified,packaged,marked and labeifed/placarded,end Cu Ft. <br /> are in elf respects in proper condition for transport accordng to applicable in tfonal and national governme regulations.V11 <br /> ACS 1. 1 <br /> " <br /> Name QhNfl <br /> Signature Dat® ' <br /> 4.TRANSPORTER 1 ADDRESS: Phone N: Ft 4 _ e <br /> W Appll Al P�rmifNtl/rlbers:6 5 0 6 <br /> 11675 White Rock Rd <br /> .t O <br /> This is a Through Shipment <br /> STERICYCLE <br /> a TRANSPORTE�%QE TJ h9co,t g MCMI waste as described a �q <br /> Pdnt/Type Name Signature Date <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: VPhone 4: <br /> a Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Rocelpt of medical waste as described above. <br /> 1 PrinUTyps Name Signature Date <br /> i6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone E: 1 <br /> 1mu Applicable Permit Numbers: II <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transferred containers, cu It to : North Salt lake,UT <br /> }. A.Designated Facility: 80.Auemste Faculty: 8C,Ahemste Facility: So.Alternate Facility: <br /> U <br /> STERICYCLE.INC. STERICYCLE.INC. STERICYCLE,INC. STERICYCLE,INC. <br /> w 1345 Doolittle Drive.Suite C 4135 W.Swift Avenue 90 North 1100 West 1312 Starr Dr <br /> San Leandro.CA 84577 Fresno,CA 93722 North Salt Lake,UT 64054 Yuba City.CA 85991 <br /> ru (510)582- 1761 If )2 5-0994 (5012 938- 1555 (530179 -of 70 <br /> 2 7531.TVG!&T25 TS(AST 22 Ctassv lndnet�� Pem*#8A ?-8,P-iA5 <br /> UJ Pt <br /> TREATMENT FACILITY:I certify that I have been authorized by the applicabil tale a c to accept untreated medical wastes and that I have <br /> Fes- received the above ind tes in accordance with the:requirenle rid In rization. NOV 2 3 2009 <br /> Print/Type Name �"2 SignatureDate <br /> 0 0 0 17 a E <br /> —u�^ ORIGINAL <br />