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�y a ^MEDICAL WASTE TRACKING FORM NUMBER
<br /> ¢ 41®t♦ S'terlcycle' IN CASE OF EMERGENCY Cc�NTACT:CHEMTREC 1-600-234-0051 STANDARD MANIFESt Ool-10.Msm
<br /> ••! rte« ..•. tom: Route �: 425 3 MDRC00792F
<br /> i.Generator's Name,Address and Telephone Number E
<br /> ATTK: Ann
<br /> ARWR CONVA ESCEW .HOSPITAL
<br /> 900 WIRTH. CHURCH STREET
<br /> LODI, CA 95240
<br /> (209) 333-1222 4/10/2009
<br /> l CUSTOMER Numsen 6041015-001 Gfmrt ron•s REGISTRATION
<br /> 2A.DESCRIPTION OF WASTE 26. CONTAINERTYPE 2C. NO.OF 20. VOLUME
<br /> REGULATED MEDICAL WASTE,n•o.s.,6.2, 20x4-1113ip) ® '.!'!'i l.#-(pati() 64 001 T b (5.9 ecce !:t) CONTAINERS r
<br /> UN 3291,PG if Cu Ft.
<br /> REGULATED MEDICAL WASTE,n,o,s„6.2, TtI'-' (B1- o} T1315-(Path) f- emu 60Tub (21
<br /> UN 3291,PG II Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.S.,6,2, T2149-(Bio) 7 TP99-(Ltd t:31) z TXa - G alae Cal Tu
<br /> C UN 3291,PG 11
<br /> � C REGULATED MEDICAL WASTE,n.as.,e,2, (IlliCu Ft.
<br /> CC UN 3291'PG it Cu FL
<br /> 1 W REGULATED MEDICAL WASTE,n.o.s..6.2, TR57 - 90 ra3 { a Cu C
<br /> W UN 3291,PG II Cu Ft.
<br /> Vr REGULATED MEDICAL WASTE,n,0.5J.2, T864 - 48 G.al. Tub (taxa) (6-4 cu ft)
<br /> UN 3291,PG 0
<br /> Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s..62,
<br /> UN 3291,PG II ST96 - 96 Gal Tub (Bin) (cu ft) Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, STt34 - 64 Gal TUb (Rio) (cu ft)
<br /> UN 3291,PG It Cu Ft.
<br /> Cu Ft.
<br /> 3.Generator's Certlrtcetion:"I hereby declare that the contents of this consignment are fully and accurately TOTALS 10- 2 t Gv Ft
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and
<br /> are in all respocts in proper condition for transaccording to applicable international and national governmental re ttlattons"
<br /> pe"
<br /> XPdntodllyped Name f Ig� 1-0tum ^ - Date '
<br /> 4.TRANSPORTEB F* -
<br /> one :
<br /> r 11875 Rhitit Koch Rd Applicable Permit Numbers:
<br /> a Rancho Cordova,CA 95742 Z Thisa Through Shipment
<br /> a Q TRANSPORTER CERTIFICATI :Recept of m icai waste as described above
<br /> ;114 PrinVlype Name Signature papa ®'40
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: V Phone#:
<br /> N
<br /> Applicable Permit Numbers:
<br /> i INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical-waste as described above.
<br /> PrintlType Name Signature Date
<br /> I
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> WApplicable Permit Numbers:
<br /> 0
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PrInitType Name Signature Date
<br /> DISCREPANCY INDICATION ' ransterll+4d eu ft to` Nps 8-
<br /> If
<br /> A.Oesigrultad Feciltty: Aftate Fecittty: Q eC.Alternate Facility: So.Alternate Facility:
<br /> CYCLE,LNG. STERICYCLE,INC, STMCYCLE,INC,
<br /> DOoiglm t?11ve,SiLQ9 C
<br /> l j � fid Ntt>�It 1 ttiG 1612 5tatr Or
<br /> �{ Sart t.ewuk*.CA 94577 North Salt Lake.UT Yuba City,CA 95921
<br /> Lt"„ (510)582-1781 (801)936.1555 (530}7510-0170
<br /> T591,TSlOST�S ��! Mass V 1 R£,.P�t 8 S
<br /> { ��QQZ P 91-02
<br /> TREATMENT FACILITY: i certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that l have
<br /> l' received the above Indicated Wast iZ,aCC b the requirement outlined in that authorization.
<br /> Prul/Typa Name SIgnature pate
<br /> 000120
<br /> ORIGINAL
<br /> .•r
<br />
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