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nx uat•e/ t tme mAT-zJ-Lu11 1WW 15: 35 P 01)9 <br /> 05/25/2011 WED 15: 43 FAX ®004/049 <br /> 0,049 SterPl:Ycle' SP�F FGtY CONr/ �� p <br /> • I..�-,r..�..d,wt' cu liREt�ko.:tt72 r1DRGVt=WFEST001.10-alfsM <br /> .Gesterator's w8me Address and Te phone Number <br /> Affil: Gavle MSZ5 <br /> 1111HOF- <br /> BIO/LOD1 MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> t <br /> LODI. CA 95290 <br /> (209) 334-3411 4/22/2011 <br /> CumutaMAtm 6089077-002 Fitamu tsRemstnattor+t . <br /> 2A.DESMPTION OF WASTE 28. CONTAWERTYPt <br /> 52PGIi vmiedM(Di3ff1�8Tt1tF�, 1xR65 - Biaspstems SLarps Trams Cart (59 cu ft) 2C.N0.OF 21t VOIultE <br /> costTERs <br /> Utr3291 <br /> 6RepulatedMWkalWaW'11os- KRB$ - Bi0SV5ttz5 'Transport Bax (4.3 cu ft) <br /> .2,PGIi <br /> ut1329t Repufakd Me�gT waste n o a Cu Ft. <br /> FF 6.2,PSi3 <br /> Q M81GII Rwlated Mcdltai wasttl,a0.8., Cu Ft. <br /> W 11N3Q91 Rc4ulaied H4edkal Mrute.n o 3.. Cu Ft <br /> 6.2,Pcll <br /> (y &U ,%2Il Regulated MBdital Waste,'LOS-- Cu Ft <br /> U1t3291Rtputatgl ldedkal Waste.n Cu Ft. <br /> 6.2.Poli <br /> U1A291,tkgulaud ttedicat lHaSte,nA S« Cd FI. <br /> 6z,Al'ili <br /> Rg$I Cu ft. <br /> *7 r I <br /> 3 (tarrorotor'a Certi[lration "!hereby deetare that the Contents of this co�uipnmem are luay er►d aauratety T�TA1.9 �f'o(�,3Z <br /> described above try tho proper r#O tn9 name.and are csassilied,paaged,marked MW 18 beasdfplecarded�and Cu Ft. <br /> Bra <br /> to all respects in proper rxiWon far ms/:;�', <br /> t OWL-alke International and national gee tat regulations' <br /> E Sipnatur <br /> Ix 4.TRJW q ;Z?2&e3!Q_ <br /> WVKItR t ADDRESS: <br /> Phone(i9iB) 985 - 5508 <br /> 11975 White Rslck Rd Appkabtepermit Numbera: <br /> 0-WRICY'Cl,ta X That is a Thcough Shipment <br /> a TRANSPORTS F�G� of m7, waste as desatbed strove. <br /> Prtnllty0e Name Signature <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Dave <br /> k' Phone r: , <br /> Applicable P8rmi1 Numbers; <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as ttasaiead above. <br /> Printrrype Nema Signature <br /> Date <br /> n U &INTERMEDIA11;HANDLER 31 TRANSPORTER 3 ARDRESS; Phone A: <br /> AppNcabie Parrott Numbers; <br /> INTERME ATE HANDLER/TRANSPORTER CERTIFICATION:Receipt o1 medical masts as dow4wd above. <br /> Print/Type Name <br /> Sipnalwa Data <br /> T.DISCREPANCY INDICATtoN <br /> Transfeed fl—contairters,Y�CU ft to : North Salt lake, LIT <br /> Q 9A Geeigneted Facility: 8B.Al10meUr Faeplty: SC.Automate Fae0lty: 00.Attemcle Fedgty: <br /> STERicYCLE.INC. STERICYCL .INC. STERICYCL.E.INC. S'fERICYCLE.INC. <br /> LL $ 4345 Doolittle Drive.Suite C 4136 W.SwiftAvenue 90 North 1100 Met te4 2 Starr Or <br /> San Leattdm.CA 94577 Fresno.CA 93722 North Salt Lane,UT 84054 Yuba City,CA 95991 <br /> z (510)562. 1781 (559)275-0884 (530)755-0585 <br /> T5?�uTSS y •nz ` T9 OST 22 (801 j 838- 4 s55 <br /> AUTOCLAVED 4 ` Chess IIndneca4on PeiwiW 91 P-B,P-M <br /> TREATMENT FACILITY:1 certify that I have been authorized by the®tltc�0 stateANNE yt ���Ereted medical wastes and that i have <br /> ta- received the Rbavetindoted wastes in accordance with the requirement outlined In that <br /> _ _ authoriza <br /> tion. <br /> Prinittype Sipalure &S5 201 <br /> _—_ Date� -r <br />