|
g 1v+owie,,rAi_vymorr-1nm,.,r%woo rvnly,lvvtviocn
<br /> 00% terocyde� CASE OF EMERGENCY CONTACT:CHEMTREC 1.000.424.9 STANDARD MANIFEST 001.10.06-STD
<br /> Route CUSTOMER NO.21132 M I)g-+RO 0 1111 i9
<br /> 1.Generator's Name,Address and Telop,hone Number
<br /> ® ATTN s Ropelidis
<br /> LA SAIETTE CONVALESCENT
<br /> 637 MST FULTOWSTREET fl
<br /> 'i'CCKT()N,CA 96204
<br /> (200)466-206,8 1125/7010
<br /> CUSTOMER NUM13Eak/45.6, M4.1� GENERATOR'S REGISTRATION
<br /> 2A.DESCRIPTION OF WASTE 28, CONTAINCIR TYPE 2C. NO,OF X13: vOI.UM9
<br /> UN320t Regulated Medical Waste,n,o.s., CONTAINERS
<br /> 6:?.,2911 T -78 iai Tub J is} 3 Cdl ) Gu FL
<br /> UN3291 Regulated Medical Waste,n;d,s.,
<br /> 6.2,P0II9-37 Cal Tub(Riga)(4.9 ou ft) c1,1 L
<br /> 623PGII Regulated Medical Waste,
<br /> 0 ,t1«"Goo Teabi(Bla)�5.9 C1t 111) 17
<br /> I UN3291 „
<br /> ,Regulated Medical Waste,n.o.s Ou r tFt
<br /> 6,2,PCI I si"i a1b( .7Ck�F T) curt.
<br /> `UN3291 Regulated Madlcal Waste,mo,s
<br /> 8.2,PG1I Cu Ft.
<br /> UN3291 Regulated Medical t� Waste,n,o,s,,6a,PGII - 043-( )NVP43-t 1W043 )Gal Tub J0 r) � ail rl:
<br /> UN3201 Regulated Medical Waste,n,os.,
<br /> G 2,PGIIKR ftfems C 4. $ R`
<br /> i
<br /> UN
<br /> Regulated Medi Waste,n.os„
<br /> 62,PGI l FI
<br /> U2.201 Regulated Medical Waste,n,e.s.,
<br /> h1 `
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS 110, dr
<br /> ascribed above by the proper shipping name.and are classified,packaged,marked and Iabeiledrpl riled,and
<br /> �----- �I`�'
<br /> r 411• II respects In proper-condition for transport a4r4rdln to appil"br.a Interneitionni alta Italia go v nmol1l I.regulatlons."
<br /> f',tttodilypa(tName.
<br /> 4k ISP01i'fER t ADDRESS: f Phone
<br /> SWI s 11:110. This 18 a�i�P#Id3ug 43ip eM Applicable PormiiNumbers:
<br /> d 13 t Hauler RogN.3400
<br /> Fre ,tea 93722
<br /> ? t 'TRANSPORTEACERTiFICATION:Receipt of medical waste as doscrtbobova
<br /> 1?e'Name Signature Date
<br /> i r 9
<br /> t3,INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS; Phone R;
<br /> CC a Applicable Permit Numbers;
<br /> I E'a
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrintMpe Name Signature Date
<br /> M S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS; Phone#i:
<br /> a Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER JTRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Printlrype Name Signature - Date
<br /> 7•DISCREPANCY INDICATION
<br /> , lBiAs.Designated
<br /> esignatedAFacility; 8B.A
<br /> lternate Pacillty: BCAlternate,Facility; BD,Alternate Facility:
<br /> ri:ycis Ino,(Autaricr) ericyala CIC. inclnat�kar) r� lo,Ina,(Auk3tlave} Covent*Marlon,l�10 Nox �611v1061h6lM
<br /> ,.
<br /> ;
<br /> Ditto 40150 8MORIM Mad�lff
<br /> LL Prean:CA 93722 4orth SM Lake,Lrr 84054 Holliatrar,CA 95023 broowl on 97 05
<br /> x (866)783-7422 "80i}988-1179 (see3-7412 (505)393-0890 /
<br /> WT8109T"27 IA- 9/iwiA-H T910'9T. 3 Permt*384
<br /> o�pC� TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br /> I— 0 received the above indicated wastes in accordance with the requirement outlined In that authorization.
<br /> Printrrype Name Signature Date
<br /> `1TratiS. d__. cardakws, cuff to :ftokv;OR m
<br /> I ransfarrea +ice `ners, : ..n C#1 fi it9 ;W.GA L11 Ake,U 1 /
<br /> e,
<br /> f_
<br /> 'PREATMENT P,/CILITY . .
<br /> .,�m,...w<...n .a..............„...,,.r.�....,.-..w..�.o..:_a,,....,..a....o...._�y�-4.........wY...a..�.,.....a,..�e„-v-..,-..w a w--�^.^^.,r._'w_-.a�,.-«..._..�...,,g....-w,....�..�....<.....,,.r...._-.d_..,» .......-.....�....�,._.__._-..„-._...._�e_....P«--_...�__.......w.t
<br />
|