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MEDICAL.WASTE TRACKING FORM NUMBOR <br /> wa: Stericycte' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-6110-234.0051 STANDARD MMIFESTOOI-10-WSVO <br /> Route 413 -5 MDRC00717H <br /> 1.Generator's Name,Address and 7elephone Number <br /> ! ATTN: Ann !I 1It <br /> I AREm cowALEscErrr 9aspiTAL <br /> 900 11t(WM CHURCH STt'tW <br /> LODI, CA 95244 <br /> 209) 333-1222 6/5/2049 <br /> CusToareA Numseh _ GMERAroR•s RmisenArtoN 0 <br /> 2A.OESCRtpnoN OF WASTE 2B. CONTAINER TYPE 2C.NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,n.e.s.,6.2 CONTAINERS <br /> UN 3291.PG 11 (Bio) Irld-vow M @tl1?! Tab (5.9 am ft) Cu Ft. <br /> REGULATED MEDICAL WASTE,n.m., , , <br /> UN 3291,PG If y' 1 1814} / T9.15-(Path) / TX15-(Chemo) 20 Gal Tait 42.7) Cu Fl. <br /> (,Z REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> RJ UN 3291,PG 11 THlt?-6814} ! rP#9-4Path) / TY69-(Chemo) 37 Gal Tub (4.9) Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,TW5 - 2t; tial Tub (Bio) (3.5 CU ft) <br /> UN 3291,PG II Cu Ft. <br /> W REGULATED MEDICAL WASTE,n.o.s.,62' <br /> W UN 3291.PG 11 '1'8.57 - 90 Gal Tub (Rio) (12 cu ft) Cu Ft. <br /> Cyr REGULATED MEDICAL WASTE.n.o.s.,6.2, <br /> UN 3291.PG 11 T864 - 48 tial Tub (viol (6,4 cu ft) Cu Ft. <br /> REGULATED MEDICAL WASTE.n.o.s.,6.4 <br /> UN 3291,PG II - <br /> Cu FL <br /> REGULATED MEDICAL WASTE,n.o.s.,64, <br /> UN 3291 PG II ST04 - 64 Gal Tub (via) (cu ft) CU Ft. <br /> kid Waste Cu <br /> Ft. <br /> 3.Generator's Certification:"1 hereby declare that the contents of this consignment are fully and accurately TOTALS `' Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and Iabellod/placarded,and <br /> are in all respects in proper conditio for transport according to applicable international and national govern regulatlo " <br /> I f I Printed(Typed Name �'" oy �(, Signature Date <br /> I 4.TRANSPORTER 1 ADDRESS: Phone 8:(916) 98 5506 <br /> S7MC YCLE Applicable Permit Numbers: <br /> ® 11876 White Rack Rd <br /> AL This a Through 3h plz�ent _ <br /> W Rancha'C�ardova,CA 9574 <br /> a TRANSPORTE FI ATIO :Receipt of rnedicat waste Edesc(l2be e. <br /> PrinYTyp@ Nam@ 1"r1r, <br /> ignature ° Date <br /> I[ <br /> S.INTERMEDIATE LER 2/TRANSPORTER 2 ADDRESS: Phone A: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recut of medical waste as described above. <br /> PrintJType Name Signature Date <br /> ro 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone t1: <br /> ac <br /> Applicable Permit Numbers; <br /> Uja <br /> WINTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of modical waste as described above. <br /> F- Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> .- Tri cu 11 to: 149ft UT <br /> ! Designated Facility: tib.Alternate Facillty: ❑8C.Alternate Facility. W.Alternate Faculty: <br /> CY IN CYCLE.INC. S TRICYCLE,INC. STMCYCLE.INC. <br /> la- Sala MGM., 22 NWIFiSaltLaiBCa Yttlxl CA t <br /> f- >: (510)=- I 55:1)275-13984 • (so))936-Ims (530)780-0170 <br /> 'fS31, aIdlS ,Lill 72 CI�sY91 R6,R-8 i5 <br /> -02 <br /> He - <br /> LU <br /> TRE @OrLWII IJV (iEprXpat I have been authorized by the applicable State agency to accept untreated medical Wastes and that!have <br /> t- receive the above In 1 `d6 i€�srs in accordance with the requirement outlined in that autharization. <br /> prdntllype�idRfa!' .t . S1gnalure Date <br /> .. ., r <br /> .G.I.L1Q L7,'li . <br /> V Vwr► b <br /> ORIGINAL <br />