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4 ®�® <br />Cut@CICl(CI@ Customer Number: <br />• <br />4021-01 <br />MEDICAL WASTE TRACKING FORM <br />1. Generator's Name and Mailing Address 2. Tracking Form Number <br />Lodi Memorial Hospital (SNF) <br />800 South Lower Sacramento <br />Lodi, CA. 95240 LL - 006155 <br />4. State Permit or ID No. <br />(209) 334-3411 <br />3. Telephone No. <br />5. Transporter's Principle Name & Mailing <br />6. Telephone Number' <br />Address <br />(909) 799-8500 <br />Ryder Dedicated Logistics <br />7. Transporter Permit or <br />3600 N.W. 82nd Avenue <br />Miami, FL 33166 <br />ID No. <br />EPA or State Med Waste ID No. <br />3120 <br />8. Destination Facility Name & Address 9. Telephone Number <br />STERICYCLE, INC. (909) 799-8500 <br />10390 ENTERPRISE DRIVE 10. State Permit or ID No. <br />REDLANDS, CA 92374 99-00060-P <br />12. Total No. 13. Total Weight <br />11. US EPA Waste Description Containers or Volume <br />A. Regulated Medical Waste S <br />B. Regulated Medical Waste L <br />C. Special Anatomical Waste <br />D. Other <br />14. Special Handling instructions and Additional Information <br />15. Generator's Certification: <br />Under penalty of criminal and civil prosecution for the making or submission <br />of false stateriMi 8 n iso(Stare on behalf of the <br />generator <br />that the contents of this consignment are fully and accurately described <br />above and are classified, packaged, marked, and labeled in accordance with <br />all applicable State and Federal laws and regulations, and that I have been <br />authorized, in writing, to make such declarations by the person in charge of <br />the generator's operation. <br />An <br />tA k--�-4NA Ard�J&/kj� <br />Printed/Typed N me S Ignature U Date <br />Trailer # �' 70 9Z %D <br />Receiver # 3_ <br />to INSTRUCTIONS FOR COMPLETING MEDICAL WASTE TRACKING FORM <br />Z <br />O , <br />U <br />White — GENERATOR COPY: Mailed by Destination Facility to Generator <br />Blue — DESTINATION FACILITY COPY: Retained by Destination Facility <br />W. Green— TRANSPORTER COPY: Retained by Transporter <br />N Pink — STERICYCLE COPY <br />Z Gold — GENERATOR COPY: Retained by Generator <br />16. Transporter 1 (Certification of Receipt of Medical Waste as described in items <br />11,12,&18) <br />= 117. Transporter 2 or Intermediate Handier <br />Wr (name and address) <br />fr <br />O <br />CL <br />Zai EPA or State Med. Waste ID No. <br />cc <br />I- <br />18. Telephone Number <br />19. State Transporter Permit <br />or ID No. <br />20. Transporter 2 or Intermediate Handier (Certificate of Receipt of Medical <br />Waste as described in items 11, 12, & 13) <br />Printed/Typed Name Signature <br />21. New Tracking Form Number (for consolidated or remanifested waste) <br />22. Destination Facility (Certification of Receipt of Medical Waste as described <br />in items 11, 12, & 13) <br />❑ Received in accordance with items 11,_12, & 131) <br />Z Printed/Teed Name <br />O <br />23. Discrepancy Box (Any <br />Z initials) <br />l'— <br />U) <br />W <br />24. Other Information <br />should be noted by item number and <br />