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Rx Date/Time MAY-25-2011 (WED) 15: 35 P. 045 <br /> 05/25/2011 WED 15: 57 FAX 045/043 <br /> ri• 7Tenzyriw :ASE OF EMERGENCY CONTACT:CHEM-MFC 1-M424o�.wwv�u rwrUa�:wt• ru <br /> ••• I ,- ftspb60i61 R=tc 9: 1913 iI cu=tomausmEaso.2932 MDRCOOABZN <br /> t.(3efletator's Name,Address and Telephone Number <br /> ATTN: Gayle Moses <br /> BIG/LODT MF.40RIAL HEST CAMPUS <br /> 800 SOUTH LOVER SACRMiENTO ROD <br /> LODI, CA 95242 <br /> (209) 339-766B 1/28/2011 <br /> cus"UMM M 6089077-003 Cat:wtm"Rewsmetont <br /> 2A.DESCRIP T1DN OF WASTE 2a. COWAINER TYPE 2C.NO,OF 211_ VOLUME <br /> �� CONTAINERS <br /> 62. ERS <br /> XpS5 - BioSpstetx Shasgs Trans Cart (39 cv ft) CIO F, <br /> Ipbal$ <br /> l1. pogledMedplWaste,n.os. KP.B X Bia2va=ems arrnrvort Sox (4.3 cu ft) <br /> Cu R <br /> pII: UNM II Reotaated Medical Waste,n.o.s.. Gtr F <br /> ` 62 P5tt)A Me*;g Waste,nos., <br /> CUP <br /> to 13"3231 Regulated Mtdkal Waste,n-os., <br /> IZ $2,F1011GiI CUP <br /> 0"32191,RegtAated Me9igl WaSSe,n,e 8., <br /> 82.PBII CUP <br /> i)NMI Repatated Medical Waste,n.ox.: <br /> 6.2,P811 Cu P <br /> UN3291.ReplNed Medical Waste,n.", <br /> 8.2,PGl1 CUP <br /> rA,F. <br /> 3.(Ieneraloes Certlncation:I hereby declare that the mnEents of this eon$lgnrneM are rely and aoeurate�y TOTALS ► � ,�p Cb:F• <br /> described above by the proper ahoft name.end are classilled packaged.marked and Iabo118dtplagrded,and <br /> are In <br /> JJ all respeds In proper n Por transport accord! to appocable IMematimW and nellomi Bove rdaI atims <br /> ElPdmedJT Name sigmiu Date <br /> 4.TRANSPORTER 1 ADDRESS: one <br /> Ph <br /> Ce t 16) 885 4S06 <br /> 11675 White Rack Rd Applicable Perme Numbers;. <br /> IL BTERICYCLE � Th--Tv is s Through Shipment <br /> N <br /> a TRANSPORTEpr FICA N.�A.jsa�Ip1"4XWCal waste as described <br /> ZL <br /> PrfnVrype Name SlgMWM Date <br /> B.INTERMEDIATE HANDLER 2/TkANSPORTER 2 ADDRESS: Pima 4: <br /> Appkabto Permit Nsmsbew, <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as desctlbed above. <br /> PdnVType Name Skpnawre Date <br /> n 4.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS ph"a Ir: <br /> t< Applicable Permll Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Remo of medical waste as described above. <br /> PWType Name Signature Date <br /> T.DISCREPANCY tNDII:AT{ON <br /> Transterrgd containers, 9'3acu It to : North Sall lake, UT <br /> r j❑6A Daalgn*W Fadtgy: FAAB.AbtemM Fadety: IN 5Q 11C.Ahemap Facill1 aD.Atmnuts Whr. <br /> STERICYCLE.INC. S.TEPICYCL.E.INC. STERICYCLE INC. STer(CYCLE,INC. <br /> 4 I:i4,ri flnnlndo nrtvp ;rtkp r 4135 W.EYA Aveinuv 90 North 1100 est 1912 Starr Dr <br /> S;m I Pandrn rA 04-577 Froznn f.A �1722 Nord-,Sat Lake UT 84054 Yuba CW,CA 95991 <br /> (510)562- 1781 (5x561 275-0904 (801)938- w5b (530)755-0585 <br /> T Af Tc40CM5 MOST 22 Class V Incineration Perm 91 A-8.P-1 0 <br /> M1---AIs.'AF OR'T1z <br /> Q <br /> AUTOCLAVED <br /> C <br /> aW TREATMENT-FACILITY.1 cerUty that t have been authorized by thDAP UNe� ee gln e t'Maced medical wastes end that I have <br /> h rweWd the aboie•Indicated wastes in accordance with the requirement outlined In that authorization. <br /> r — <br /> PrGtUrype Name Slpnatute Kra 1 1 Data <br />