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.�..�. .�.....�-...� __ ....__._...-..._. ..._.....�.....��...o.F.•i rNlmo wS�iv�M v/1.11• <br /> NIEDICAL WASTE TACKING Ft3RM;�tUMBLA <br /> 0.0.** Ster(cycle' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1.800-234-0051 sTANOARO MANIFEST001.10.08$T0 <br /> o• ho»,tI g how. <br /> Route! #: 413 -1 <br /> 1.Generators Name,Address and Telephone Number <br /> AT!'N: Ann 11111111111111 <br /> ARBOR COWAT.>aSCENT HOSPITAL <br /> 900 14ORTEI CHURCH STREET <br /> LpDI, CA 95240 <br /> 209 333-1222 7/10/2005 <br /> CUSTOMER NUMBERGENEfiATOR's REGWRATtaN N <br /> 2A.DESCRIPTION OF WAS - CONTAINER TYPE 2C.NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,mo.s,.62, CONTAINERS <br /> ON 3291.PG N 14-(310) "14-(Path) 44 gal Tub (5.9 ou ft) Jar Cu rt. <br /> REGULATED MEDICAL WASTE,n.o.s.,62, <br /> UN 3291.PG U T1321-(Bio) / THIS-(Path) / TY15-(Chestlo) F0 Gal Tub (2.7 Cu Ft. <br /> CIC REGULATED MEDICAL WASTE,n.o.s..6.2, <br /> Q UN 3291,PG 11 TB49-(Bio) / TP49-(Path) / TY49-(Chemo) 37 Gal Tub (4.91 Cu Ft. <br /> REGULATED MEDICAL WASTE,ao.s,.62, T83•S - 26 Gal Tub (Bio) (3.5 cu ft) <br /> UN 3291.PG 11 Cu Ft. <br /> W REGULATED MEDICAL WASTE,n.o.s..6.2, <br /> W UN 3291,PG 11 T857 - 90 Gal Tub (Bio) (12 cu ftt Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG 11 TB64 - 48 Gal Tub (Biu) (5.4 cu ft) Cu Ft. <br /> REGULATED MEDICAL WASTE,mo.s.,6.2, <br /> UN 3291,Pa.0 a - „d t k Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s..6.2, , <br /> UN 3291,PG 11 ST04 - 64 Gal Tub (Rio) (cu ft) Cu Ft. <br /> Pharmaceutical Waste Curt. <br /> 3. nerator'a rtlRcati `I hereby declare that the contents of this consignment are fully and accurately TOTALS b. t , � c Cu FL <br /> A.. <br /> ribed above the proper shipping name,and are classified,packaged,marked and Iabeiledrpladarded,and �-- - <br /> (are Ijn all respect in proper condition for transport according to applicable International and national governmental Ions” �j t <br /> { 1 Printedfad d Name r ' �� Signature Date {'(0' <br /> 4.TRANStPATER 1 ADDRESS: Phone is: <br /> STERICYCLE Applicable Permit Numbers5:: - 1 <br /> 9011875 White Rock Rd <br /> CL ® This is a Tht'ough Shipment <br /> i <br /> a do Rancho CordovarCA 95742 Q TRANSPORTER CERTIFICATIO :Rec el t of medical waste as described&=7Z <br /> Print/Type Name SignatureData ` 10-M <br /> 6,INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: V Phone#: <br /> w Applicable Permit Numbers: <br /> e <br /> INTERMEDIATE HANDLER/TRANSPORTER CERMCATION:Receipt of medical waste as described above. j <br /> Print/Type Name Signature Date <br /> ., 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone a: II <br /> a: Applicable Permit Numbers: <br /> 21 1 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Printrrype Narne Signature Date <br /> 7.DISCREPANCY INDICATION I <br /> Transfetred oontalners ou ft to : North SaEt Lake UT 1 <br /> SA.Designated Facility: 86.Alternate Faclgty: SC,Alternate Faelrlty: 8D.Alternate Facility. <br /> 45 t CYCLE INC. STENCYCLE,INC. STERICYCL.E.INC. STERICYCLE,INC. I! <br /> U <br /> 1 I be br(ve.Sults C 4136 W.Svi tAvenue so Nom 1100 West 1612 Starr Or <br /> u`t t:•n 1osandr6,0A ti*5677 Preen,CA 93722 Horth Sett Lake.UT 84054 Yuba City,CA 95991 <br /> (510)562. 1781 (559)275-0994 (801)936-1555 . 1530)790.0170 <br /> ua TS311 TSIOST25 T'S/OST 22 Class V Indnerdon P-61 P-115 <br /> [ Perri t#91-02 <br /> TREATMENT FACILITY: I certify that i have been authorized by the applicable state agency to accept untreated medical ad_hatl have <br /> P received the abn a Indic s in accordance with the requirement outlined in that au rization. RECC�vL,p <br /> Print/Type Name Signature Date l <br /> 009 <br /> 4. . <br /> ME0lCALWASTE <br /> ORIGINAL. <br />