Laserfiche WebLink
•�A —^— MEDICAL.WASTE TRACKING FQ14M NUM86( <br /> !a• S4eriicycle' <br /> w• racacc6yr.op..R�adwHa: STANDARD MANFE$i pai.tMa87D <br /> ROIN CASE p � 6H ,1M3� <br /> MDRC009FID <br /> i <br /> ? <br /> 1.Generator's Name,Address and Telephone Number <br /> Av <br /> nn <br /> ARBOR CONVALESCENT HOSPITAL <br /> 900 NORTH CHURCH STREET <br /> � LODI. GA 95240 <br /> (209) 333-1222 7/2812010 <br /> CusTomen NUMBER15093 GENERA4ows ReoisTRATioN N <br /> i <br /> 2A.DESCRIPTION OF WASTE. 26. CONTAINERTYPE 2C. NO.OF 20. VOLUME <br /> CONTAINERS <br /> S 2,PGIi Regulated Medical waste,n.o.s., TS18-(Bxa) J 14-{Peale) 44 Gal Tub (5,9 au ft) Cu Ft. <br /> 6 2,P611i Regulated Medical Waste,n.o s G) / T1115-(Fath) / TY1S-(Chemo) 20 Gal Tub (2.7 <br /> UN3291,Reoulated Medical Waste,n.o.s., Cu FI, <br /> (� 6.2,PG11 TR49-(Bia) / TP49-(Path) / TY49-(Chemo) 31 Gal Tub (4.9 <br /> Cu FI. <br /> Q UN3291Regulated Medical <br /> Waste-n.o.s., T835 - 26 Gal Tub (bio) (3.5 cu ft) <br /> 6.2.PGli Cu FL <br /> W UN3291,RegutatedMedical Waste,n.o.s., T857 - 90 Gal Tub (Bio) (12 cu ft) <br /> Z 6.2,1`611 Cu Ft. <br /> UN382,PG1i Regulated Medical Waste,n.o.s., TB64 - 48 Gal Tub (Bio) (6.4 au ft) Cu Ft. <br /> I ON3291,Regulated Medical Waste,n.o.s., <br /> 6.2,PGfI 17 7e au ft <br /> Cu Ft. <br /> UN3291 Regulated Medical Waste,n.o.s.-, <br /> 6.2,PGII ST64 64 Gal Tub (Bio) (9.67 cu ft) Cu Ft. <br /> Pharmaceutical Waste <br /> .�'�, Q Cu Ft. <br /> 3.Generator's Certlnn: <br /> catlo 'I hereby declare that the contents of this consignment are fully and accurately TOTALS ® .� �3 'f'� Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and labeltedlptacarded,an <br /> ars inf all respects in proper condition for transport acoo ding to applicable International and national governmen I rag I tions." <br /> _ IPrint Nan-* RWK :6 Signature Data �U <br /> cc 4,TRANSPORTER 1 ADORES Phone <br /> &6> say - 5506 <br /> �t E 11675' Whitt Rock Fid Applicable Permit Numbers: <br /> 4a 0 <br /> IL wTERICYCLE fihis is a Through Shipment <br /> nx <br /> a TRANSPORT t;{TJF %i)ua ptPfikfi&wale as described above. „�✓'— �T t <br /> ~ Print/lype Name , ® gnature Date <br /> S,INTERMEDIATE HANDLER 2!TRANSPORTER 2 ADORERS' -7 Phone N: <br /> n Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrinVType Name Signature Date <br /> ' 6,INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone N: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDt_ER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrinVlyps Name Signature Data <br /> 7.DISCREPANCY INDICATION <br /> Transferred containers, cit ft to : North Salt take,UT <br /> y p.Oesignakid Faetllty: 8B.Anemate Facility: 6C.Alternate Facility: 060.Alternate Facingr: <br /> d STERICYCtE,INC. STERICYCLE.INC. STERICYCLE INC, STERICYCLE,INC. <br /> LL <br /> 1345 Doolittle Drive.Suite C 4135 W.Swift Avenue 90 North 1100Vkk 1812 Starr Or <br /> �- San Leandro.CA 94577 Fresno.CA 93722 North Salt Lake,UT 84054 Yuba C' CA 95991 <br /> W (510)582-1781 (559,)275-0994 (80111936-1555 (5801755-0585 <br /> a2- T53I.TSIOST25 TWST 22 ClassV tndnetauon PenTM Qi P-6.P-1t6 <br /> a , <br /> f � TREATMENT FACILITY cot that I have been authorized by the applicable state agerIft to accept untreated medical wastes and that I have <br /> F- received the ab aceta tes In accrordance with the requtrerllen d In t orI;ation. �p <br /> PrintnlypoName � � � Signature Oats JUL 2 9 205 <br /> v59C <br /> -- ORI{3IM <br />