Laserfiche WebLink
MEDICAL WASTE TRACKING FORM NUMBER <br /> i i A Stericycle' I CASE OF EMERGENCY CONTACT:CHEMTREC 14WO-424-s STANDARD MANIFEST oat-1p-0{rs7D <br /> • "'"�vr`°•"''a'•'x Route #: 413 -e Custof�067 1a FWMV2 MDRC00ALK6 <br /> i.Ggrlerator's Name,Address and Telephone Number <br /> ATS N t Gayle Moses <br /> BIO/LORI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> 209 334-3411 3�25�2011 <br /> CusrotaEA NUMBER 09;(n)RQ(0) _ GENERATOWS Rectirw tor1,9 <br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> UN3291,Regulated Medical Waste n.0. ., CONTAINERS b <br /> 62.PGI1 0GMM i(R65 — 31aSyst. Sharps Trans Cart (59 cu £t) 151' Cu Ft. <br /> UN3291,Regulated MediW Waste,mos., <br /> I 6.2.PGd KRB$ — Bio$v5tem5 Transport Box (4.3 cu ft) <br /> E Cu Ft. <br /> IM UN3291,Regutaled Medical waste,mo.s., <br /> p O 6.2,PGII <br /> H" UN3291,Regulated Medical Waste,n.c.s.,ft Cu Fr. <br /> Q 6.2.PGII <br /> Cu Ft. <br /> W 1.1113291,Regulated Medical Waste,n.o.s., <br /> Z 6.2,PG3 <br /> Lu Cu FI. <br /> UN3291,Regulated Medical Waste,n.o.s„ <br /> 62.1`0I1 Cu Ft, <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,n.0.5., Cu Ft. <br /> 6.2.PGII <br /> Cu Fl. <br /> RgBI Cu Ft. <br /> 3.Generators Certification:`I hereby declare that the contents of this consignment are fully and accurate) TOTALS ► r -1• Cu F:. <br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/ r <br /> Tare in all respects in p ndition for transport according to applicable Intern nal and natio al governm egulatiorts: I <br /> ` �Prinled/Typed Na 06C� /jV`� Signa Data 5 �r{ <br /> 4.TRANSPORTER t ADDRESS: <br /> � 995 - 55Q6 <br /> 1- Applicable Permit Numbers: <br /> cc 11875 White Roak Rd <br /> 4 a STEAICYCI,E L -1 Thim i5 z Through 3hipmcnt <br /> a a TRANSPORT ZIFMAT t fit, waste as described . <br /> ~Cc <br /> Print/Type Name Signature Date 3 A5-1 <br /> _, S.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: f Phone#: <br /> a <br /> o¢ Applicable Permit Numbers: <br /> Uj <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Recaipt of medical waste as described above. <br /> — Print/Type Name Signature pale <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS; Phone#; <br /> F3 <br /> J Applicable Permit Numbers: <br /> RSH INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. , <br /> z <br /> - Print/Type Name Signature Dale <br /> •7. REPANCY INDICATION <br /> Transferred containers, ou It to : North Salt lake, UT <br /> T n$A.Dosignmed Facility: 'TO.Attemate Facility: 8C,Aharnato FacBlty: 813,Altomato Faclllry; <br /> v ST>=BICYCLE.INC. gTE I,CYCLE.INC. 0TERICY CE,SNC. CYC E,INC. <br /> 1345 Doolittle Drive.Suite C 413 w Swift Avenue 0 North 1 00 west tart r <br /> San Leandro.CA 54577 Fresno.CA 03722 North Salt Lake,UT 84054 Yuba C' ,CA 85991 <br /> Z 11 f 510)5B2-1781 f 5591 275-0994 (80 1)938-1555 (530)765-0585 <br /> I a TS31.TSIOST25�y E,p�EC�TSf4ST 22 Classv Ss�dslecatiast Permit 8t P-0,P-1 t5 <br /> M P11 TREATMENT FACILITY:i d ty tfiat I have been authorized by the applicable slate agency to accept untreated medical wastes and that I have <br /> ¢I— $ received the above indicated wastes in accordance with the requirement outlined in That authorization. <br /> �r Print/Type Name � � T_ —Signature Date <br /> ORIGINAL rrtRe65654Shf 934� <br />