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• - MEDICAL WASTE TRACKING FORM NUMBER'
<br /> A®®IR 5tericycle' IN CASE(W
<br /> Moi s ..R.a�gxv+ EMERG$CY4Dy:CHENTREC I-Wt)234-01 STANDARD MANIFEST oot-io-oa sTD
<br /> outs
<br /> MDRCOO'7A3A
<br /> 1.Generator's Name,Adnti andTetgphone Number !1111111
<br /> � { t
<br /> A.T'P[�l: Anti �lialw t! 11 ij
<br /> i ARBOR CONVAE,ESCENT HOSPITAL,
<br /> 1 900 NORTH CHURCH STREET
<br /> LODI, CA 95240
<br /> (209) 332-1222 3/17/2009
<br /> CusTOMER NUMBER 6041015-001 GENERATORS REGISTRARON 8
<br /> 2A.DESCRIPTION OF WASTE 20. CONTAINER TYPE 2C.NCL OF 2D. VOLUME
<br /> REGULATED MEDICAL WASTE.n,o.s.,6.2,Tgi4-(Bio) / TP14-(Path) 43 Gal Tub (5.9 cu ft:) CONTAINERS
<br /> UN 3291,PG 11 Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, T321-(B.io) / T1315-(Fath) / TY1S-(Chemo) 20 Gal Tub (2.7)
<br /> UN 3291,PG II Cu Ft.
<br /> CC REGULATED MEDICAL WASTE,n.o.S.,62. TB49-(Bio) / TB49-(Fath) / TY49-(Chemo) 37 Gal Tub (4.9)
<br /> Q IV 3291,PG 11 Cu Ft.
<br /> ,q REGULATED MEDICAL WASTE.n.o.s.,6.2, T035 - 26 Gal Tub (Bio) (3.5 au ft)
<br /> Ir UN 3291,PG it Cu Ft.
<br /> LIJ REGULATED MEDICAL WASTE,n.o.s„62, 7857 - 90 Gal Tub (Bio) (12 cu ft)
<br /> W UN 3291,PG li
<br /> Cu Ft.
<br /> U, REGULATED MEDICAL WASTE,n.o.s„6.2. T364 - 48 Gal Tub (Bio) (6.4 au ft)
<br /> UN 3291,PG Ii Cu Ft.
<br /> AEGULATED MEDICAL WASTE,n.o,s.,6.2,
<br /> UN 3291.PG It ST96 - 96 Gal Tub (Bio) (au ft) Cu Ft
<br /> REGULATED MEDICAL WASTE,mo.s.,6.2. ST64 - 64 Gal Tub (Bin) (au ft)
<br /> UN 3291,PG It
<br /> ttarmaceutica Wasteo”
<br /> Cu Ft.
<br /> 3.Generator's Certification:"i hereby declare that the owtents of this consignment aro fully and accurately T®TALS ® Cu FI
<br /> described above by the proper shipping name,and are classified,packaged,marked and laballed/placarded,and
<br /> are in all respects In proper condition for transport according to applicable international Bpd national goveriVentitl4egul
<br /> 1 - �Printedrrypad Name r 6"w jy411)
<br /> 4.TRANSPORTER I ADDRESS: Phe Arerf; (9Fr 985 - 5508
<br /> STERICYCLE
<br /> Applicable Per n Numbers:
<br /> m 11075 White Rock Rd
<br /> a O This is a Through Shipment
<br /> �r°n R�txahes Cc>a~ciav�.CA 9574?
<br /> u°C TRANSPORTER CE1R�TIIF.InCAAT=--
<br /> am waste as described above, 6 C�
<br /> PmveypBName (,1r33irL Signaturea6Ei Date �< 7 /
<br /> 5.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: V Phone a:
<br /> any
<br /> Applicable Permit Numbers:
<br /> x INTERMEDIATE HANDLER/TRANSPORTER CERTIFICA'T'ION:Reeetptof medical waste as described above,
<br /> PdnVType Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phoria N:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDIER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. i
<br /> IPrintrrypo Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Transferred containers, cu It to: North Salt lake, UT
<br /> a H11A.Designated Facility: 88.Alternate Facility: [�SC.Aftemate Facility; 6D.Attemste Facility:
<br /> rJ�Irv�l t= STE ICYCLE,INC. STERICYCLE.INC. STERiCYCLE,INC.
<br /> 46 Dao)iitle D W.Sw*AKenue 90 North t 100V►�est 1842 Starr Dr
<br /> San L.eandro,CA 9457 ” estw.CA '93722 tynrrh fi;;*t aka i IT 900 A Yuba City.CA 95591
<br /> I i� (M)582-1761 (359)276-0994 (801)936-1555 f 5301 790-0170
<br /> I z TS314- 11 .TS/OST25 `�� 5��lS 1, ,MOST 22 Class V Incineration P-S,8415
<br /> W I
<br /> Pprrm*A1-A9
<br /> DG TREATMENT FACILITY:I certify tha h tbeen authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F- received the above�¢,icated wastes In accordance with the requirement outlined in that authorization.
<br /> Print/Type Name_ G f Signature Date
<br /> aiDes28
<br /> i
<br /> ORIGINAL rfdl(teAlartSDtidS(a ts.ar„aryto 1
<br />
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