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Rx Date/Time MAY-25-2011 (WED) 15: 35 P. 003 <br /> 05/25/2011 WED 15: 4.3 FAX 2003/049 <br /> :;0 Stericycle• lltd4� @sem Y CONTACT Ct'+EUTREC 1400e424s30o MDRC6�',, FE5roa'•rooa-= <br /> • CUSTOMER N0.21132 <br /> AifiTa: <br /> I.Generator's Name,Address and Telephone Number III HIM11111111-e'+t�+�i1 i 113���i <br /> BIOILODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAI RMONT DRIVE <br /> LODI. CA 95240 <br /> (209) 334-34 11 4129/2011 <br /> OMMUM 6069077--002 cl> lvtrstismsrrunoHd <br /> 2A.DESCRIPTION OF WASTE za. COKAWER TYPE 2C.NO.OF 20. VOLUME <br /> U ')Regulated M� RR65 - BiOSyste= SLaxpr Trans Cast (59 tw ft) CClITAlNER8 <br /> UM291 � CU FL <br /> 6.2,PGIi � ' <br /> MDR - Biasyntaae Transport Box (4.2 au it) <br /> M UN3291,RegU4kd Medical t►la518,n.o.s, Cv FI. <br /> p 6 2,PGII <br /> UN3291 RegUl3ttd Medio tVaste,MU., CU R <br /> 6A PGii �� <br /> Ul MI1 itegagted MSI Waste.a.os_ <br /> W 6.2.PG11 <br /> (y UN3281,Requhted Medical 10413 ,nm.s„ Cr' <br /> 6.2 PGn <br /> UNW91,Regubted Mtdkal Waste,n.u.s., C"E• <br /> 6.2,PGII <br /> UN3291,Fkoviated Medical Wane,n o�. Cu <br /> FL <br /> 6.2,PGII <br /> CU FI. <br /> RSBI .5to <br /> 3.Generator'a 06milicatt6n:01 hereby deaare that the eontera3 of lfds eonsigrtmini ere IUlly and aoWrately TOTALS ► D ,� Cu Ft <br /> described ab"by the proper"Ping name,and are dasstGed,patdmged,marked <br /> and labellKliplacarded,end <br /> We In all r9$PWs In proper condtion for Iranspo:t avoordln tp apptlaabla International and national governmental latlom' <br /> I �Pr[nledfTyped Name <br /> Signature Date <br /> 4,TR3A14SPORTER 1 ADDRESS: Phone iL91S 85 - 5 <br /> 11875 White Rock Rd � Applicable Permit Numbers: <br /> STERICYCL'E X This is a Through 9hipsaant <br /> IL 7TRANSPORTERS a l§1 l waste as dasalW above. Tram Rep.#3404 <br /> PrrnVlype Name Slgnaturo Date <br /> 5,INTERMEDIATE HANDLER 21TRAMSP0RTER 2 ADD SS: Phu"e_ <br /> N y� <br /> F• Applicable Permit Numbers: <br /> INTERMEDIA'T'E HANDLER/TRANSPORTER CERTIFICATION*.Receipt of medical waste as described above. <br /> Prinitf p"Name 819nature Date <br /> w 6.INTERMEDIATE PANDLER 31 TRANSPORTER 3 ADDRESS: Phone e. <br /> Applicable Parm3l Numbers; <br /> a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as descrbed above. <br /> Printll}rpa Name Signature Date <br /> 7.01$CFiEPANC+I INDICATION c�'j� <br /> Trams#erredy— contalners,YV.5&CU It to : North Salt lake, UT <br /> 3 j ❑ AhMolad Fadltty: 8.Atumrate Fauuty aC.Atterhate Fadltty ao.Altemate Foc[Mr. <br /> CE STERICYCLE.INC. STERICYCLE.INC. STERICYCLE.INC. STERICYCLIE,INC. <br /> 1345 Doolde drive.Shite C 41x5 W.SvV tAvenue 9Il Notch 1 too vilest 1612 St21rDr <br /> ! San Leandro.CA 44577 Fresno.CA 93722 North Sett Lake,LIT 84054 Yuba ty.CA 95991 <br /> I'S113)562- 1781 (5591 276-0994 (801)930. 1556 1530 755-05gg <br /> TS3Iogx'.%�TwWD <br /> iz T3/0ST L) bass <br /> �trIndnerad wpeer~r w 91 TS/MT 80 <br /> (� "EATMENT FACIUJTY:i certify that I have been aulhofted by the t f i gta a ager yE acceptuntreatedTI medical wastes and that t have <br /> F- received the above indicated wastes In accordance with the requirement outlined in that authorization. <br /> Pdntffype Namo•.w n. SignatureOat. `-� <br />