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• _ ... .. .� ^s�__ _ MEDICAL wASTtwt`�dCkit�(-i�6RM NU Moss
<br /> !®® Sterlcycle' IN CASE OF EMERGENCY CONTACT-CHEMTREC 14800.234-0DSI STANDARD MANIFEST 001.10-WSTD
<br /> A�® narxuq naq..t.euc4.g u,s:
<br /> Pouts #: 412 -i 1�sllTxr^rtn°7 rn
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ARBOR CONVALESCENT HOSPITAL
<br /> 900 NORTH CHI3RCH STREET
<br /> LODI, CA. 95240
<br /> (209) 233-1222 /7!2 gju-
<br /> CUSTOMER NUMBER Rr GENERATOR'S REGISTRATION 0
<br /> 2A.DESCRIPTION OF WASTE" 1213. CONTAINER TYPE 2C.NO.OF 2D. VOLUME
<br /> REGULATED MEDICAL WASTE,n.o.s..6.2, CONTAINERS
<br /> i UN 3291,PG 11 TB14-f8'o) / -(Pat 1 51 Gal 1-uhf5 9 rl, ) Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s„6.2,
<br /> { UN 3291,PG II T521-(Bio) j TB15-(!lath) / 7Y15-(Cheno) 20 Cal flub (2.7) 1 1 Cu Ft.
<br /> CC REGULATED MEDICAL WASTE,mo.s.,62.
<br /> t O UN 3291,PG ii TP49-(Bio) / TP49-(Path) / mY49--(Chamo) i7 Gal Tub (4.9) Cu Ft.
<br /> (^ REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> C UN 3291,PG 11 T535 - 26 Gal Tub (Bio) (2.5 au ft) ' Cu Ft.
<br /> W REGULATED MEDICAL WASTE,mo.s.,6.2.
<br /> i UN 3291,PG II '$57 - 90 Gal Tub (Bio) (12 cu ft) 11.01 Cu Ft.
<br /> j O REGULATED MEDICAL WASTE,n.o.s.,6.2, JV
<br /> UN 3291,PG II r.'RKA - Aa «.1 M..& rR4„1 rA A .,.. x-% ACu ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> UN$291,PG 11 Cu Ft.
<br /> REGULATED MEDICAL WASTE,n.o.s.,62, "` " '� "' " `"'
<br /> UN 3291,PG II q1VR4 - A4 r_ 1 T0, rtk+nl ra W7 ... Et% Cu Ft.
<br /> Pharmaceutleal Waste
<br /> Cu Ft.
<br /> 3.Generator's Certification:"i hereby declare tha the contents of this consignment are fulty and accurataly TOTALS-00, Cu Ft.
<br /> described above by the proper shipping name,and atsclassified,packaged,marked and labelled/placard n a
<br /> are in all respects in proper condition for t port acro ' g tc appIf b ytmat'o I and 1AIWAg{p'V8� i r 9 til
<br /> r 7
<br /> Printedfr ped Namo St nature Data `e-
<br /> 4.TRANSPORTER 1 ADDRESS: Phone S:
<br /> U, (916) - 5•
<br /> STERFCYCLE
<br /> Applicable Permit Num495 rs:
<br /> qn 1187 White Rock Rd In I Thim i-z ,a Through 5hipmanr,
<br /> rn F�ntxho Cordotra,CA 95742
<br /> a a TRANSPORTER CERTIFICATIO :Receipt of medical waste as described ab
<br /> PrinVType Name -04s "1 _Signature Date
<br /> 8,INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: V Phone R:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Ptlnt(We Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> �; INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Print/Type Name Signature Data
<br /> 7.DISCREPANCY INDICATION
<br /> 6 rPn,0 rrori r n a a rit ft IQ• Al rfh 4art lztriz I IT
<br /> Q 8A,Designated Facility: LJ ea.Aitemats Facility: 8C.Alternate Facility: Lj SD,Alternate Facillty:
<br /> .r,TFRI(-:Y(:l J" IN(- STERICYCLE.INC. STERICYCL E.WC. STERiCYCLE,INC.
<br /> 0 I?A5 Doolittle Driva.Suita C 4125W.Q-wftAvpnue g0 Norah 1100 Mst 1612 StBrr Dr
<br /> uQ. San L,eandro.Q-%04577 Fremo.CA 03722 tdnrfn F,a1r i akp IIT R4171.54 Y sbb City.CA c51aai
<br /> (510)602-1761 (559)275-0994 (2Uf)1036-1655 (553p01 7913-Of 70
<br /> TS31.TSICJST25 TS/OST 22 Class Incineration PA P-115
<br /> 1Parreis#n 142 1
<br /> TREATMENT FACILITY:i cer tha have been authorized by the applicable state agency to pt untreated medical wastes and that I have
<br /> 11- received the above Indi a A accordance with the requirement outlin at au ion. AUGy �p
<br /> I Print/Type Name 0 �'® RSignature Date nU1 Zoll)
<br /> i
<br /> ORIGINAL
<br />
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