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MtbIdA1 WASTE-eRACKINQ FORM NtJMEE�R
<br /> i®® E'TIC�iC��®
<br /> OCASE OF EMERGENCY CONTACT:CHEMTREC 1.600.424-930iF STANDARD MANIFEST 001-10•DO-STD
<br /> 'Route 0: 126 14 CUSTOMER NO,21132 MUR(JO UR UFI
<br /> 1.Generator's Name,Address and Telephone Number I ! I
<br /> ATTN:Gus Ropalidis I f I t I !I
<br /> LA SALETTR CONVALESCENT
<br /> 537 FAfiC FULTON STREET
<br /> STOCKTON,CA 95204
<br /> (202)468-2060 11/8/201$
<br /> CUSTOMER NuMeER 6081745-018 45-018 GENERATOR'S REGISTRATION N
<br /> 2A.DESCRIPTION OF WASTE 219. CONTAINER TYPE 20. NO,OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste,n o,s„ CONTAINERS
<br /> 6.2,PGIi T804-28 Gat Tub(Blo) 3.7 Cu ft CU Ft.
<br /> 8 23PGII Regulated Medical Waste,n,o,s,, TB49_37 Gal Tub (Rio)(4.9 cu ft) Cu Ft,
<br /> O 623PG1�Regulated Medical Waste,n,o,s„ TB 14-44 Gal Tub(Rio)(5.9 cu ft) 1 Cu Ft,
<br /> 82,PG1i Regulated Medias!Waste, T821-( VTP164 Mi54 )20 Cal Tub(2.7CUFT) Cu Ft,
<br /> tetUN3291 Regulated Medloal Waste,n.0.s„
<br /> i W 6.2,PGiI Cu Ft.
<br /> 6:2,UN3Pell 91 Regulated Medicai Waste,n,D.s„ WB43 NP434 1WC434 Gal Tub(5.7CUFT) Cu Ft.
<br /> 6 2Regulated Medical Waste,n,o.s,,
<br /> ,pall KR -Slorystems Cardboard Sox 4.3 cu ft
<br /> CuF.
<br /> UN3291 Regulated Medical Waste,n,o.s„
<br /> 6.2,PO[I cu Ft
<br /> UN3291 Regulated Medical Waste,n.0.s.,
<br /> 6.2,PGII QU Et.
<br /> 3,Generator's Certification:"I 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 labelled/pla�rded,and
<br /> are In all respects In proper condition for4f4nsport according to applicable international and national governmental rsgulatlons"
<br /> 1 /l
<br /> I
<br /> PrInIe5Mped Name Sig nature Data
<br /> 4.TRANSPORTER 1 ADDRESS: Phone M:(866)783.7422
<br /> Stericycie Inc. ElThIS 19 a Through Shipmlent Applicable Permit Numbers:
<br /> 4135 W.Stwift Aa Hauler Reo 3400
<br /> resno,CA 93722
<br /> a TRANSPORT R CERTIFICA ON:Receipt of medical waste as described above.
<br /> Printltyps Name Signature Date f f s*8
<br /> S.INTERMEDIATE H NDLER 2/TRANSPORTER 2 ADDRESS: Phone d:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrinMpe Name Signature Date
<br /> n 8.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone k:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrinMpe Name - Signature Date.
<br /> 7.DISCREPANCY INDIOATION
<br /> jog 8A.Designated Facility: 819,Alternate facility: 8C.Akemata Facility: 80.Alternate Facility:
<br /> Sterlavole Ino,AutocWn Stericv+de, Inc. Incinerate Stericycle, Inc.Autoclave Covanta Marion, Inc Incinerate
<br /> 4135 W, train Aue 90 N.Foxboro OrNe 1561 Shelton 06m 4850 Brocklake Road NE
<br /> u. rrasnn, !North Batt lake,UT 84054 Holster CA95023 Brooks,OR S7306
<br /> (868)783- t o�+`flz (801)930-1171 (888)781-7422 (605)393-0380
<br /> W ff TS/0ST-22 8/JA-38 TS/OST-83 Permit#384 NOV 09 2010 1 1
<br /> PH
<br /> TREATMENT FACILITY:I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the abovpjp,0,i9wastes in accordance with the requirement outlined in that authorization,
<br /> PrinMpe Name Signature Date
<br /> Transferred containers, cu ft to :Brooks,OR,
<br /> Transferred containers, cu ft to :N.Sat Lake,UT
<br /> ORIGINAL
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