|
N— MEDICAL WASTE TRACKING FORM NUMBER
<br /> •Oef Stericycle, IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800.234-0051 STANDARD MANIFEST 0e1.10-o5-STO
<br /> s r am«iuyreooa.xdyR k: Route #: 913 -a MDRC007S6R
<br /> 1.Generator's Name,Address and Telephone Number 1111 E
<br /> ,ARBOR CONVALESCENT HOSPITAL
<br /> 900 NORTH CHURCH STREET
<br /> LODI, CA 95240
<br /> (209) 333-1222 4/24/2009
<br /> CUSTOMER NUMsen 6041015-001 GENERATows RecisrnwnoN a
<br /> 2A.DESCRIPTION OF WASTE 28, CONTAINER TYPE
<br /> 2C. NO,OF 2D, VOLUME
<br /> REGULATED MEDICAL WASTE,n.o.s_6.2,TS14-(iiia) / TP24-Q ath) 44 Gal Tub (S-9 cu Et) CONTAIN RS r
<br /> UN 3291.PG 11 Cu Ft.
<br /> REGULATEDMEDICALWASTE.n.o.s.,6.2, TB21-(Bi.o) / TB15-(Path) / TY15-(Chemo) 20 Gal Tub (2.7)
<br /> UN 3291,PG II Cu Ft.
<br /> Cr REGULATED MEDICAL WASTE.n.o.s..6.2,TB49-(Bi o) / TP49-(Path) / TY49-(Chemo) 37 Gal Tub (4.9)
<br /> Q UN 3291,PG II Cu Ft.
<br /> Q REGULATED MEDICAL WASTE.n.o.s.,6.2, TB315 - 26 Gal Tub (Bio) (3.5 cu it)
<br /> CC UN 3291,PG If Cu Ft.
<br /> Uj REGULATED MEDICAL WASTE,n.0.s.,6,2,T557 - 90 Gal Tub (Bio) (12 cu it)
<br /> IZ UN 3291,PG If Cu Ft,
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> TH59 - 48 rel Tub (Bio) (6.9 cu ft)
<br /> 0 UN 3291,PG 11
<br /> Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o,s.,6.2,
<br /> UN 3291,PG 11 8T98 - 96 Gal Tub (Bio) (cu ft)
<br /> Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.S.,6.2, ST64 - 64 Gal Tub (Bio) (cu it)
<br /> UN 3291,PG 11 Cu Ft.
<br /> 2ltm3CeutIC211 WaSte
<br /> q Cu Ft.
<br /> 3.Generator's Certification:^I hereby declare that the contents of this consignment are fully and accurately TOTALS 1111- r J ( Cu Ft.
<br /> described above by the proper shipping name,and are classified,packaged,marked and labolled/placarded,and
<br /> are In all respects in proper co/nd�itiioo,,n fo`r transport according to applicable international and national governmental regulations:
<br /> Fa'PdritedrTypedName � ���' Signature
<br /> Data
<br /> 4.TRANSPORTER 1 ADDRESS: Pho a#:(916) 985 - SSOS
<br /> ul
<br /> STE-RICYCLE Applicable Permit Numbers:
<br /> j 11875 White Ronk Rd NO
<br /> g N Rsnaho Cordoras,CA 9574 't`}ti3 is Through 3hipmetzt
<br /> a Z TRANSPORTER CERTIFICATIO :Receipt of medical waste as described above.
<br /> I a
<br /> Print/Type Name Signature Date— :/' -0
<br /> 5.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: VPhone#:
<br /> 11aApplicable Permit Numbers:
<br /> R 2
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br /> PrintrType Name Signature Date
<br /> 6,INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> a¢ Applicable Permit Numbers:
<br /> f r INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION:Receipt of modlcat waste as described above.
<br /> �Zx
<br /> PrinVType Name Signature Date
<br /> Ix
<br /> 7.DISCREPANCY INDICATION
<br /> Transferred containers, cu ft to : North Salt take,LIT
<br /> 8A.Designated Faalllty: 8B.Affomate Facility: 8C,Alternate Facility: 80.AtterrGata Facility;
<br /> . TFalrvrl tN . STERIC,YCL.E,INC. STERICYCLE.INC. STERICYCLE,INC.
<br /> u 1 6 L)ocditile D' , •. SwRt Avenue 90 North 1100 tklest 16 12 Starr Lir
<br /> San Leasxtro GA X4511 o CAS 93122 NnrVh Satr I;*A I IT RQR4 Yuba City.CA 86%q
<br /> (510):762-171314 3'J�7�� 659)275-0984 (804)m- 1356 (6301790-0170
<br /> TS3i.TSfOST2b 8'39Y31"'IVIS ClassVInciner�ation P-6,P-115
<br /> Ulf .
<br /> ppmsit*AI.112 i
<br /> fl,tt� f�, ,
<br /> TREATMENT FACILITY:!�certify a Iga� 'ffeen authorized by the applicable State agency to accept untreated medical wastes and that I have
<br /> t•- received the above I #Rated wastes in accordance with the requirement outlined in that authorization.
<br /> PrinlJType Name r Signature Date
<br /> ORIGINAL
<br /> rpllt1etier6D6dR•1 aa.er,-?rY1a
<br />
|