Laserfiche WebLink
MEDICAL WASTE TRACKING FORM N <br /> UMBER <br /> IN CASE 06EEM}GtCSTANDARD MANIFEST 001.0ae•STD•wA®®e0 Steritycle8eMDR 007Q53 <br /> 1.Generator's NaAddress and Telephone Number <br /> AT77T'N. Ann 1 (t <br /> ARBOR CONVALESCENT EOSBITAL <br /> 900 NORTH CIURCH STREET <br /> LODT, CA 95240 <br /> (209) 333-12222 7/24/2005 <br /> CUSMMEa NUMOER 6041015-001 GENEHAsows REGISTRATION� <br /> 2A.DESCRIPTION OF WASTE 29. CONTAINER TYPE 2C.NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,n,o.s.,6.2 14-(Bin) TRU-(Path) 44 Sal Tub (5.9 au !t) CONTA ERS <br /> UN 3291,PG It r Cu Ft. <br /> REGULATED MEDICAL WASTE,n.0S.A2, Y521-`Bao) TB15-(Path} I TY15-(Chemo) 20 Gal Tub (2.7 <br /> UN 3291,PG II <br /> Cu FL <br /> tx REGULATED MEDICAL WASTE,n.o.s.,6.2, T1149-(Ban) TP49-(Path) TY49-(Chemo) 37 Gal Tub (4.9) <br /> ® UN 3291,PG II Cu Ft. <br /> -.4. REGULATED MEDICAL WASTE,n.a.s.A.2, <br /> CC UN 3291.PG 11 Cu FL <br /> LU REGULATED MEDICAL WASTE,n.o.s..6.2, TB57 - 90 Gal Tub (Rio) (12 cu ft) <br /> W UN 3291,PG If Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, TB64 - 48 Gal Tub (bio) (6.4 cu ft) <br /> UN 3291,PG It Cu Ft <br /> REGULATED MEDICAL WASTE,n.o.s..6.2, ST96 - 96 Gal Tub {Bio) {17.78 cu tt) <br /> UN x291,PG 1l Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, ST64 - 64 Gal. Tub (Bio) (9.67 cu ft) <br /> UN 3291,PG it Cu Ft, <br /> alms" c we-me <br /> I Cu L <br /> 3.Generator's Cartlflcatlow"I hereby declare that the contents of this consignment are fully and accurately TOTALS 0- 1 Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and labellediplacarded,and <br /> are in all respects in proper condill for transport riling to appNeable International and national governmental regulations" 7 <br /> I f Pdnted/Typed Name '°' Slgnaturo tJ) �� ate `0 <br /> a of <br /> 4.TRANSPORTEf14 $�;LE PhoneN: t <br /> Ial 11875 IWhhite Rock Rd ApplEcabie Permit Numbers: <br /> a Rancho Cordova,CA 95742 ® This is a Through Shipment: <br /> rR <br /> a Q TRANSPORTER CERTIFICA I N:Receipt of medical waste as described above. <br /> ~ <br /> Print/TypeName- Signature Dato -2 <br /> YO <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#: <br /> n a Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Print/Type Name Signature Data <br /> co 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone N: <br /> a Applicable Permit Numbers: <br /> 8� <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> x <br /> Print/TypeName Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transferred_ __ _ containers, cu tt to : Noah Salt lake,UT <br /> A.Designated Faculty: 613,Alternate Facility: E]aC.Alternate Facility: aD.Alternate Facility: <br /> RICYCLE.INC. STERICYCLE,INC. STERICYCLE,INC. STERICYCLE,INC. <br /> v 1345 Doolittle Drive,Suite C 4135 W.SM Avenue 80 North 1100 West 1612 Starr Or <br /> San Leandro,CA 94577 Fresno,CA 93722 North Sal Lake.UT 84054 Yuba City.CA 95991 <br /> (5 10)562-1781 (559)275-0994 (SOL)936-1555 (S30)790-0170 <br /> TS31.TSIOST25 TS/OST 22 Class V Ir►cIneration P"-6,P-115 <br /> Perri=91-02 <br /> OI o�C TREATMENT FACILITY:I certify that I have been authorized by the apptic to o accept untreated medical wastes and that I have <br /> F- received the above Ind s in accordance with the require til Jt t Z <br /> Print/Type Name � Signature �; Date V <br /> ia0,-303 <br /> ORIGINAL 4t t4d 2141, <br />