|
Ak
<br /> • MEDICAL WASTE:TRACKING FORM NUMBER
<br /> A 0 Stericycie' IN CASE OF EMERGENCY CONTACT:CHEMT13EC 1-800-234.0081 STANDARD MANIFEST 001.10.06-STO
<br /> .�R1R r..,,..RawLq RaR� Route 9: 425 -2 MDRC006VTV
<br /> 1:Generator's Name,Address and Telephone Number
<br /> ATTN-. Ann
<br /> kRBOR CONVALESCENT HOSPITAL
<br /> I 00 NORTH CHURCH SST
<br /> ODI, CA 95240
<br /> (209) 333-1222 12/26/2008
<br /> CUSTOMER NUMBER gn 4 1 o 3 C; nniGENERATOR'S REWStRATIDN A
<br /> 2A.DESCRIPTION OF WASTE _28. CONTAINER TYPE 2C.NO.OF 2D. VOLUME
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, CONTAINERS
<br /> UN 3291,PG If T 9157 - 90 Gal Sub (Bio) (12 cu ft) Cu A.
<br /> REGULATED MEDICAL WASTE,a.o.s.,6.
<br /> UN 3291.PG II itm 44 Gal Tub (dio) (5.9 OU tt) Cu Ft.
<br /> CC REGULATED MEDICAL WASTE,n.o.s.,fi.
<br /> Q UN 3291.PG 11 21 2t) Gal Tub (Bio)(2,7 CU it) ri Cu F1.
<br /> i Q
<br /> REGULATED MEDICAL WASTE.n,o.s.,6. 49 _ 37 Gal Tub (Rio), 16.7 Le (4.9 Cu ft)
<br /> � tfN 3291,PG II Cu Ft.
<br /> W REGULATED MEDICAL WASTE,n.as.8.2.
<br /> W UN 3291,PG 11 15 _ 20 Gal Tub (Path) (2.7 cu tt) Cu Ft.
<br /> a REGULATED MEDICAL WASTE,n.o,s.,6.2,
<br /> UN 3291,PG If 71t15 - 20 sial Tub (Chem*) (2.7 cu tt) Cu Ft.
<br /> I REGULATED MEDICAL WASTE,mas..6.2,
<br /> i UN 3291,PS fl 2035 - 26 Gal Tub (Bio) (3.S cu ft) Cu Ft.
<br /> ! REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> UN 3291,PG 11 Cu Ft.
<br /> Phi Tmacetilical Waste I Cu Ft.
<br /> 3.Generator's Certification:I hereby declare that the contents of this Consignment are fully and acc ratatly TOTALS® Cu Ft.
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelledVacarded,and
<br /> are in all respects in proper con 'tion for transport according to applicable international and national governmental regulations"
<br /> 1 - IPrirded/TypedName Si nature SeA✓l sernera Date
<br /> Q 4.TRANSPORTER 1 ADDRES Plwne T.9]6) 98b _ b5o6
<br /> STERICYCLE A ficabloPermitNumbers:
<br /> 11875 White Rock Rd �
<br /> FrCLo Rancho Cordova,CA 95742 El This is a Through shipment
<br /> C16 QQ TRANSPORTER CERTI ON:Receipt of medical waste as described above.
<br /> ~ Prinnpe N Signature - Oste
<br /> 5.INTERMEDIATE HANDt E 2/TRANSPORTER 2 ADDRESS: Phone A:
<br /> fl� Applicable Permit Numbers:
<br /> i
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PrinUType Name Signature Date
<br /> , M
<br /> S.INTERMEDIATE HANDIER 3/TRANSPORTER 3 ADDRESS: Phone A:
<br /> dw Applicable Permit Numbers:
<br /> o,�
<br /> Wn
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Racelpl of medical waste as described above.
<br /> a
<br /> PrinMpe Name Signature Date
<br /> 7.D RFPANCY INDICATIO
<br /> NFrdmM%6%red twrrtah;ers, au R to: North Sall Wa.UT
<br /> BA.Designated Facility: 80.Alternate Facility: ❑8C,Alternate Facility: D 8D.Alternate Facility:
<br /> FriCYINC, CYCLE,INC. CYCLE.INC. STERICYCLE,INC.
<br /> a 345[�coifiMa�,sto C 435 W.Son Avet tue North 1100 MSM 2775 E.20 St!"t
<br /> ( w
<br /> an Leandm,C.A 94577 F vsno,G0. 93722 Hath Sat Lake.UT 841)54 Vernon.CA 90023
<br /> ( 59)275-am 801)936-1555 1323)362-3000
<br /> 22 ass V Indneradon R-6,P-115
<br /> 1 r. . . . OM0 91.02
<br /> ertify that I have been authorized by the applicable state agency to accept untreated medical wastes and that t have
<br /> Wa e Indicated wastes it1 accordance with the requirement outlined in that authorization.
<br /> rint/Typelda R Signature Date
<br /> 1
<br /> ORIGINAL
<br />
|