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• MEDICAL.WASTE TRACIC04 FORM Nt2M$Ek <br /> 0w0• Stericyde' W CASE OF <br /> ®® Pnte.lirg . OFEMERGENCY CONTACT.CHEMTREC 1.800.234-0051 STANDARD MANIFEST 001.14-WSTO <br /> 1'Ph.ft'&d0Route µ: 413 -2 1Sn 0000V <br /> I.Generator's Name,Address and Telephone Number <br /> ATTN: Ann <br /> ARBOR CONVALESCENT HOSPITAL <br /> 900 NORTH CHURCH STREET <br /> LODI. CA 95290 <br /> (209 333-7.222 1/22/2010 <br /> CusTneven NumsER 609103GENERATOR'S R£GIS1RAMN N <br /> 2A.DESCRIPTION OF WASTE 2e. coNTA1NERTYPE 2C.NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,n.os..6.2, ~y CONTAINERS <br /> UN 3291,PG II 14-(Bio) TP14-(Poch) 44 Gal Tub (5.9 s1a ft) !' JJ Cu FL <br /> REGULATED MEDICAL WASTE,n.a.s.,6.2, TB21-(Bio) / TB15-(Path) / TY15-(Chemo) 20 Gal Tub (2.7 <br /> ON 3291,PG if Cu Ft. <br /> pC REGULATED DICALWASTE,n.o.s.6.2, <br /> O UN 3291,PG!( TB49-(Bio) / TF49-(Path) / TY49-(Chetao) 37 Gal Tub (4.9 <br /> a <br /> Cu Ft.REGULATED MEDICAL WASTE,mo.s.,6.2, TE25 - 26 Gal Tub (Bio) (3.5 cu it) <br /> IM ON 3291,PG 11 Cu Ft. <br /> W REGULATED MEDICAL WASTE.mo.s.,6.2, <br /> Z ON 3291,PG 11 T557 - 90 Gal Tubi (Bio) (12 cu it) <br /> ul <br /> REGULATED MEDICAL WASTE,n.c.s.,6,2, Cu Ft. <br /> ON 3291,PG II TB64 - 4e Gal Tub (Bio) (6.4 cu it) Cu Ft. <br /> REGULATED MEDICAL WASTE,ma.s.,6.2, <br /> ,ON 3291,PG 11 ST96 - 96 Gal Tub Bio (17.78 au it) Cu Ft, <br /> REGULATED MEDICAL WASTE.n.o.s..6.2, <br /> ON 3291,PG n 8764 - 64 Gal Tub (Bio) (9.67 cu it) <br /> Cu Ft <br /> PDarinaceirtieal Waste <br /> �^ Cu F. <br /> 3.Generator's Certification.*'I hereby declare Etat the contents of this consignment are fully and accurately TOTALS 0- ✓ Cu Ft. <br /> described above by the proper piping name,and are classified,packaged,marked and labelted/plaearded,and <br /> are in all respects In proper c Rion to a ding to livable' tional and national g ental re <br /> Y !PrintedrTypad Name Signature Date <br /> 4.TRANSPORTER I ADDRESS: Phon916) 985 -� 5506 <br /> This is a Through Shipment <br /> 11875 White Rock Rd Applicable Permit Numbers: <br /> �� STERICYCLE � <br /> a TRANSPO HR1�IP N1;PtAIpt$�tt�B&waste as described above. <br /> N 1� <br /> Print/Type Nano Signature Date <br /> S.INTERMEDIATE HAN t.ER 2/TRA SPOFITER 2 ADDRESS: Phone N; <br /> Applicable Permit Numbers; <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medial waste as described above. <br /> PdnVType Name Signature Date <br /> �u 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone N: <br /> g 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 /> Transferred containers, cu It to: North Salt: lake,UT <br /> A.Designated Facility: 88.Altentata Facility: 8cC.Alternate Facility: 8D.Alternate Facility: <br /> C) 5TE5R CYGLE.IhIC. �W.Stvllt.INC. RAR <br /> 1' NG. �, GYC�r INC, <br /> 134 t�oolittle Drive.Suite G t Avenue o 1 West IT r <br /> San Leandm.GA 84577 Fresno.CA 93722 North Salt Lake,UT 84054 Yuba Gtr,GA 95991 <br /> (5 111)582-1781 (559)275-0994 (00 1)938-1555 (530)790-0170 <br /> Lu <br /> TS3i,TSIOST25 TSIOST 22 Classy Incineration PenTit#91 P-6, A 15 <br /> 1 <br /> Pil TREATMENT FACILITY:I certify that 1 have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> ' I received the abov ed s in accordance with the requirement outlined in that authon ation. sl 5 2010n 411 <br /> Printrrype Name /� Signature Data ,SAN 2 <br /> 000569 <br /> _ _ ORIGINAL rptl�Abrr50645td 1Q.6w <br />