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® 8. Destination Facility Name & Address 9. Telephone Number I,_ Steric Cle 4021 fs Y Customer Number. STERICYCLE, INC. (909) 799-8500 10390 ENTERPRISE DRIVE 10. State Permit or ID No. MEDICAL WASTE TRACKING FORM Cl) Z Z 1. Generator's Name and Mailing Address 2. Tracking Form Number 0 Lodi Memorial Hospital W A. Regulated Medical Waste S 975 so Fairmont avenue a v Lodi, Ca. 95244 LL- 006135 cc 4. State Permit or ID No. Z (209) 33"11 r 3. Telephone No. 5. Transporter's Principle Name & Mailing 6. Telephone Numbef Address (909} 799-8500 Ryder Dedicated Logistics 3600 N.W. 82nd Avenue 7. Transporter Permit or Miami, FL 33166 ID No. EPA or State Med Waste ID No. 3120 C. Special Anatomical Waste D. Other 14. Special Handling instructions and Additional Information 15. Generator's Certificatio : Under penalty of criminal an6 civil prosecution for the making or submission of false staterMi n wris, I declare on behalf of the generator that the contents of this consignment are fully and accurately described above and are classified, packaged, ma ed. a Bled in accordance with all applicable State and Federal I re Iati s�nd that I have been authorized, in writing,to make c e arat' ns b t person in chafoe of a 16 Printed/Typed Name Trailer # — .2 ,0 % - LS Receiver # INSTRUCTIONS FOR COMPLETING MEDICAL WASTE TRACKING FORM White — GENERATOR COPY: Mailed by Destination Facility to Generator Blue — DESTINATION FACILITY COPY: Retained by Destination Facility Green— TRANSPORTER COPY: Retained by Transporter Pink — STERICYCLE COPY Gold — GENERATOR COPY: Retained by Generator 16. Transporter 1 (Certification of Receipt of Medical Waste as described in items 11, 12, & 13) Printed/Typed Name 17. Transporter 2 or Intermediate Handier (name and address) EPA or State Med. Waste ID No. > '9 --�- Date 18. Telephone Number 19. State Transporter Permit or ID No. 20. Transporter 2 or Intermediate Handler (Certificate of Receipt of Medical Waste as described in items 11, 12, & 13) Printed/Typed Name Signature 21. New Tracking Form Number (for consolidated or remanifested waste) 22. Destination Facility (Certification of Receipt of Medical Waste as described in items 11, 12, & 13) ZI Received in accordance with items 11, 12, & 13 Z Printed/T eed Name 0 1= 23. Discrepancy Box (Any Z initials) P U) W 24. Other Information should be noted by item number and 8. Destination Facility Name & Address 9. Telephone Number I,_ STERICYCLE, INC. (909) 799-8500 10390 ENTERPRISE DRIVE 10. State Permit or ID No. a 0 REDLANDS, CA 92374 99-00060-P Z 12. Total No. 13. Total Weight W11. US EPA Waste Description Containers or Volume W A. Regulated Medical Waste S a B. Regulated Medical Waste L C. Special Anatomical Waste D. Other 14. Special Handling instructions and Additional Information 15. Generator's Certificatio : Under penalty of criminal an6 civil prosecution for the making or submission of false staterMi n wris, I declare on behalf of the generator that the contents of this consignment are fully and accurately described above and are classified, packaged, ma ed. a Bled in accordance with all applicable State and Federal I re Iati s�nd that I have been authorized, in writing,to make c e arat' ns b t person in chafoe of a 16 Printed/Typed Name Trailer # — .2 ,0 % - LS Receiver # INSTRUCTIONS FOR COMPLETING MEDICAL WASTE TRACKING FORM White — GENERATOR COPY: Mailed by Destination Facility to Generator Blue — DESTINATION FACILITY COPY: Retained by Destination Facility Green— TRANSPORTER COPY: Retained by Transporter Pink — STERICYCLE COPY Gold — GENERATOR COPY: Retained by Generator 16. Transporter 1 (Certification of Receipt of Medical Waste as described in items 11, 12, & 13) Printed/Typed Name 17. Transporter 2 or Intermediate Handier (name and address) EPA or State Med. Waste ID No. > '9 --�- Date 18. Telephone Number 19. State Transporter Permit or ID No. 20. Transporter 2 or Intermediate Handler (Certificate of Receipt of Medical Waste as described in items 11, 12, & 13) Printed/Typed Name Signature 21. New Tracking Form Number (for consolidated or remanifested waste) 22. Destination Facility (Certification of Receipt of Medical Waste as described in items 11, 12, & 13) ZI Received in accordance with items 11, 12, & 13 Z Printed/T eed Name 0 1= 23. Discrepancy Box (Any Z initials) P U) W 24. Other Information should be noted by item number and