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MEDICAL WASTE T ACKING FARM MDER <br /> "® 5tericyele' IN CASE OF EMERGENCY CONTACT:CHEMIREC 1-800.234-4051 STANDARD MANIFEST DOI-W06•STD oil <br /> n�e�ray .e.oxsy u,e <br /> to At: 41.3 1 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN: Ann <br /> IIIIIIIIIIIIIIIIII � IIIIII 1111111 <br /> ARBOR COWALESCENT HOSPITAL <br /> 900 NORTH CHURCH STREET <br /> LODI, CA 95240 <br /> c <br /> CusTouER NUMBER GeNtinATOR•s Rowt"A'WH# <br /> 1 2A.DESCRIPTION OF WASYr CONTAINER TYPE 2C.NO.Of 20. VOLUME <br /> REGULATED MEDICAL WASTE.n.o.s.AZ CONTAINERS <br /> UN 3291,PG IIIt- TP {- R caa !Gt Cu Ft. <br /> REGULATED MEDICAL WASTE,0.0.8j.2, <br /> UN 3291,PG it TB21-(Sio) / T815-Math) / TY15-(chemo) 20 Gal Tub (2.7) Cu Ft. <br /> QC REGULATED MEDICAL WASTE,n.os.,6.2, <br /> p <br /> LIN 3291•PG11 T649-(Bio) / TP49-(Path) I TY49-(Chemo) 37 Gal Tub 14. <br /> Cu Ft. <br /> a REGULATED MEDICAL WASTE,n,o.s.,6.2, TB35 — Tu (B0) ( <br /> 26 Gal b i3. cu S ft) <br /> UN 3291.PG It Cu Ft. <br /> W REGULATED MEDICAL WASTE, <br /> 1Z UN 3291,PG 11 TB57 - 90 CA1• Tub (Bio) (L2 CU ft) Cu Ft. <br /> ar REGULATED MEDICAL WASTE,n.os.,6.2, <br /> UN 3291,PG II Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG II Cu Ft. <br /> REGULATED MEDICAL WASTE,n,o.s.,6.2, <br /> UN 3291.PG 11 - Cu Ft. <br /> Phimn ceuticat Wasle Cu Ft. <br /> 3.Generator's Certification:W hereby declare that the contents of this consignment are fully and accurately TOTALS 111' pt Ft <br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and <br /> are In all respects in proper condition for transport according to applicable International and national governmental <br /> regulations" q <br /> - I Prinied/Typed Name � r"l GAU D � Slgnsture ''` '° —' Date <br /> Ix 4.TRANSPORTER 1 ADDRESS. Phone#: (g3S} 985 <br /> W STERICYCLE Applicable Permit Nutnbars: <br /> a O1.3875 White Rock Rd <br /> CL ® This is a Through Shipment <br /> 0Rancho Cordova,CA 95742 <br /> X.Q� TRANSPORTER C RTIFICA11 N:Receipt of medical waste as described above. Oct <br /> m <br /> ~ Prlm/rype Nae `r Signature Date / <br /> S.INTERMEDIATE HANDLER 2(TRANSPORTER 2 ADDRESS: V Phone#: <br /> 1h <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PdnVType Name Signature Date <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> -a2 Print/Pipe Name Signature Date <br /> 7.DISCREPANCY INDICATION mad anem <br /> Designated Facility: all.ANPRU"N alty: 8C.Alternatea <br /> Facility: Co.Co.Attete Facility: <br /> ECYCkE INC S'1ER1CYCi.E,INC. STERICYCLE,INC. STERICYCI!,INC. <br /> 1345 00oltttl9 6t1vs.Butte C 4136 W.9Yt Avenue 90 Nat11t 1100 Wast 1612 err Or <br /> Sian Laandro,CA 94677 Praisno,CA 93722 North Sal Lake.UT 84054 Yuba COY.CA 95991 <br /> rz (St0)st,2-1781 (559)275-0996 (801)936- 1555 (630)790-0170 <br /> °i1 <br /> T93 1.TSIOST25 TSfOST 22 Class V Indneratlon P-6,P-115 <br /> PertW 91-112 <br /> LU TREATMENT FACILITY:I rt' that I have been authorized by theenff�� <br /> pt untreated medical wastes and that i have <br /> received the above i ' ed es in accordance with the requirern. �+ hhPdnt/Type Name Signature D o ✓ ���t Y�i.J <br /> L2 9 2009 <br /> ti��:�1e��f f <br /> wA� <br /> ' ORIGINAL <br />