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SANITIC 2900 Apron Ave., Bldg. #1260 MANIFEST Atwater, CA. 95301 NO: M 1-866-SANITEC - Fax 209-388-024 4 7 E T.. NO.: 0.133 D �i MEDICAL WASTE TRACKING DOCUMENT NAME OF COMPANY - GENERATOR / CUSTOMER; WASTE TYPE; T.D. NUMBER: ELEPHONE NUMBER Lodi Memorial HospU (West Facilfty)- Bio Waste 2W -1,39-7M ADDRESS OW S. Lower Sacramento R& Lodi, CA 95240 /certify that the information provided above is true and correct NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE 2489 INITIALS LEANDRO PERALES COMPANY NAME TELEPHONE NUMBER sanitte (M) MO -02M ADDRESS DATE MEDICAL WASTE COLLECTED 29W Apron ft 1260 Atwater. Ca 9&301 REGISTRATION No. OTHER REG No. NO. OF CONTAINERS COLLECTED CERTIFIEDTOTALWT. OFCONTAINERS 28G 32G 38G 48G 96G Other CA -5134 CA- I certify that the information provided above is true and correct and that only untreated medical wastes are contained in this load. I am aware that falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State authorized facilities. NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE TRANSFER STATION: NAME SANITEC PERMIT NUMBER SIGNATURE OF TRANSFER REPRESENTATIVE TS 145 716�ECEIVED NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS COMPANY NAME TELEPHONE NUMBER ADDRESS DATE MEDICAL WASTE COLLECTED REGISTRATION No. OTHER REG No. NO. OF CONTAINERS COLLECTED CERTIFIED TOTAL WT. OF CONTAINERS 28G 32G ]" � Other I I certify that the information provided above is true and correct and that only untreated medical wastes are contained in this load. I am aware that falsification of this manifest may result in forfeiture of my transporters registration and/or the privilege of utilizing State authorized facilities. NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE COMPANY NAME Sanitee USA. Inc. fib a Sanitec TELEPHONE NUMBER #913) 504-ON3 ADDRESS 9M Nwds Avmue, Surt Vakey, CA 91352 PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED 'F GST 20 DISCREPANCY INDICATION SPACE certify that i have been authorized by the State of California Department of Health Services to accept untreated medical wastes and that / have received the above indicated wastes in accordance with the requirements outlined in that authorization. SEE ATTACHIED DOCUWNT NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE