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-- MEDICALWASTE7RAGKING FORM NUMBER
<br /> ®"O•`a* 5kericycte'
<br /> IN CASE OF EMERGENCY TACT:CHEMTREC 1.600.234-0051 STANDARD MANIFEST OOI-10.06•STD
<br /> ►akn,� ,a�� ter: Route #: -1 MDRC007GW5
<br /> 1.Generator's Name,Address and Telephone Number
<br /> i
<br /> AM:�LApn�srt yTAr li 11 11 !1 1111 1111
<br /> ARBOR
<br /> 901) WRTR CHURCH STREET
<br /> Lt1DI, r:A 95240
<br /> (209) 333-1222 5/29/2009
<br /> CUSTOIIot NumsER 6041015-001 GENERATOR'S REGISTRATIONN
<br /> 2A.DESCRIPTION OF WASTE 29. CONTAINER TYPE 2C.NO,OF 20. VOLUME
<br /> REGULATED MEDICAL WASTE,n.D S,,6. CONTAINERS '
<br /> UN 3291,PG II )3ili-(>3it1f Yll lt-Cpath) 444 9a1 rob tI5.9 oTs et) Cu Ft.
<br /> REGULATED MEDICALWASTE,R.O.s.A- , 5-(Path) / MS-(Cheat") 20 Gal Rub (2.7)
<br /> UN 3291,PG 11 Cu FI,
<br /> CC REGULATED MEDICAL WASTE,n.o.s.,6.2, T1349-(Bio) I TP49-(Path) / TY49-(CheMo) 37 Gal Tub (4.9)
<br /> O UN 3291,PG II Cu Ft.
<br /> 4 REGULATED MEDICAL WASTE,n,o s.,6.2. 21; Gal ° •' Cu
<br /> CC UN 3291,PG 11 Cu Ft.
<br /> W REGULATED MEDICAL WASTE,n.ox.,62, TD57 - 94) Gal Tub (Dia) (12 cel ft)
<br /> W UN 3291,PG II Cu FL
<br /> REGULATED MEDICAL WASTE,n.o.s.,62, T864 - 48 Gal Tub (si-ot (6.4 eu ft),
<br /> UN 3291.PG 11 Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,62, ST96 - 96 Gal Tub (Bio) (ru ft)
<br /> UN 3291,PG II Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,62, STfA - 64 Gal Tub (Hio) (CU £t) Cu FL
<br /> UN 3291,PG II
<br /> ttrmacst tt e
<br /> .Q Cu Ft.
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS` a / Cu FL
<br /> described above by the proper shipping name,and are classified,packaged,marked and habe8ed/piacarded,and
<br /> are in all respects in proper condition for transport accordingto applicable international and national governman 1 regulations"
<br /> rf
<br /> Printedffyped Name 0OW01 f 14'i Signal Date
<br /> 4.7RANSPORTE,,,�QTOR S Pone4 916) b
<br /> ; +C Appticablo Permit Numbers:
<br /> 11875 Uihite Rock Rd .his is a Through Shipment
<br /> as Rancho Cordova,CA 95742
<br /> m
<br /> a Q TRANSPORTER C IFICA ON: ipt61 medical waste as describe##.
<br /> l
<br /> ~ Print/Type Name Signatur I
<br /> 3/2
<br /> S.INTERMEDIATE HA 2/TRANSPORTER 2 ESS: F Phone 6:
<br /> Nor Applicable ermitN rs:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrinVrype Name Signature Data
<br /> .� S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone A:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PrinMpe Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Translbemed contaalWS, cu 8 to: Naft Salt take,UT
<br /> A.Dealgnated Facility: 80.Alternate Facility: 8C.Ahwnate Faculty: Q 90.Altemate Facility:
<br /> STES7EMCYCLE,INC. STERICYCLE,INC. STERICYCIE,INC.
<br /> 4135 W.SVA Averute 9a North 111100 Wed 1612 S'tWT Of
<br /> Q Shut Frmw,CA 93722 North Salt Lake,LIT 840x4 Yuba CITY,CA 95991
<br /> °A• (610) 1781 (559)275-0994 (Silt)936-I"s tS3tl)790-0170
<br /> X535
<br /> ;401 TSWT T2 Class V Irictriendlon P-61 P-115
<br /> �Q��!r,����} 7�� .6002. I� 91-art
<br /> 7'FiEA1t111ENT FACIA'I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F- g received the above Indicated wastes in accordance with the requirement outlined In that authorization.
<br /> )f Print/TVIZA13'`�'- SSignature Date
<br /> AR1QiNAt. COM ted
<br />
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