|
MEDICAL WASTE TRACKIING 1 t�iMt41~
<br /> • Stericycle' IN CASES F E £RG£ CY CONTACT:CH£MTREC t-800-4124443300 M �+STAIN7D�A/R►Dpb-ugUtt6EtiT 001-1040,41D
<br /> [ �• 9%"I,.&-%dn UA: Polite +.t: ��:3 � CuZttl"§TCaR'NR.R?J2 :'t ARC09,',l'>M
<br /> t.Generator's Name,Address Ann
<br /> ndTetephone Number
<br /> ATTN jjj j) JjjjjJ j JJjjj)( ] ) J
<br /> ARBOR CONVALESCENT HOSPITAL 111111 yll 1[11 11f1 !!4 (I (1 1I y (ltllill 11 (1 ti
<br /> 900 NORTH CHURCH STREET 1
<br /> LODI. CA 95240
<br /> (209) 333•-!222 4122/2011
<br /> CusmMNurret:R 6041015-001 G9N MAWR%REfs5tM—e
<br /> 2A.DESCRIPTION OF WASTE 28 CONTAINERTYPE 2C,NM OF 20. VOLUME
<br /> UN3291.Regulated Medical Waste,ox s' TBl4-(Sid} 2-4-(Path) 44 Gad, Tub (5.9 cu ft) CONTAINERS
<br /> 6.2.PGII � Cu Ft
<br /> UN3291Re9ulatedMediWWaste,n,0,5., T821-(Bio) / TB15-(Path) / 7Y15-(Chemo) 20 Gal Tub (2.7
<br /> 6.2.PGIi Cu Ft.
<br /> CC 623�iiRegulated MedicalWaste,n•o.s,, TB49-(Bio) / TP49-(Fath) j V419-(Chemo) 37 Gal Tub (4.9 Cu Ft
<br /> CCI' UN3291,Regulated Medical Waste,ri os., - a i a 3. cts t
<br /> 6.2,PGif Cu Ft.
<br /> I&A UN3291,Regulated Medical Waste,n.o.s., TBS7 - 90 Gal Tub (Bio) (12 cu €t)
<br /> Z 6.7,PGII
<br /> all Cu Ft, J
<br /> {r) UN329t Regulated Medical Waste,n.O.$,, cu
<br /> 6.2,PGii TB64 - 4$ Gal Tub (Bio) (6.4 £t) 1
<br /> Cu Ft.
<br /> 111,13291,Regulated Medical Waste,n.o.s., o (Bio) (17.78 au ft) Cu Ft.
<br /> 6.2.PGII $T96 - 96 Gal Tub Bio [
<br /> UN3291,Regulated Medical Waste-n,o.s., ST54 - 64 Gal Tub (Bits) (9.67 cu £t) t
<br /> 6.2.PGII
<br /> f:u Fl.
<br /> e o
<br /> Cu Ft.
<br /> 3.Generator's Certification:`I hereby declare that the contents of this Consignment are fully and asauatety, TOTALS ® J [ Cu Ft,
<br /> described above by the proper stripping name,and are classified,packaged,marked and Mbelled/Pt ecarded,and --
<br /> aro in all respects in proper oonft for tran,(Csry Irl rding to applicable international and national gaemm gufado
<br /> Printosfflyped Name Signature
<br /> 4.TRANSPORTER I ADDRE : It 1 Pho 016) 988 ^ 5506
<br /> 11875 White Rock Rd Applicable Permit Numbers:
<br /> O TERICYCGE �( `Phis icr Through 3hipmcnt
<br /> a
<br /> y g
<br /> a q TRANSPORTEOI�FI�dA :�e.3f it di IS waste as described /
<br /> Printlryps Name A, Signature Date
<br /> r 5,INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone!I V M:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDIER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above,
<br /> PrintrType Name Signature Dale
<br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone M.
<br /> c� Applicable Permit Numbers:
<br /> 0 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of mod6Cal waste as described above.
<br /> { PdnUTyps Name Signature Date
<br /> y.DISCREPANCY INDICATION
<br /> Transferred containers, cu ft to : North Sait lake,UT
<br /> 8A.Designerad Faclllty: Des.Alternate Facility: ®8C.Akomato Facility: 8D.Alternate Facifky:
<br /> STERICYCLE.INC. STERICYCLE.INC. f7l�YC NC. CYC INC,
<br /> 1345 Doolittle Drive.Suite C 4135 W.SwiftAvenue BSlonh 1 SAO West 181tr Dr'
<br /> u San Leandro.CA 94577 Fresno.CA 93722 North Sak Lake.UT 84054 Yuba City.CA 85991
<br /> I t•- (6103 5B2-1761 1`559)275-0994 (801)936-1555 (530)756-0585
<br /> TW.TSIUST215 TS(QST 22 rJlassV k%dr*raa w Pent 91 P"6.P-i t s
<br /> a
<br /> wPit TREATMENT FACILITY:I certify that 1 have been authorized by the applicable state ages t accept untreated medical wastes and that I have
<br /> received the above indica fad Cva S''n accordance with the requirement outlm rf�IFi that iatlon. M
<br /> Prkrt/rype Name Signature it Date APR 2 5 MI
<br /> X4248
<br /> ORIGINAL rc1I8eR1mt5U64Std an ta,r
<br />
|