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06/17/2011 FRI 12: 14 FAX P. 003 <br /> r�an 7iU4 U4CASE OF EtERGENCY CONTACT. 0003/028 <br /> Poutre 413 30 Clit ARiREC t�etl�=ag3ap ownww.�r,w.,rear w,.av wano <br /> I <br /> Name,Address andVephtane NuMI*r CUSTiDAtERxa2tt3x Mi�gf'Qt1A7'}T1 <br /> A'�TN: Gs)ale Mose <br /> r��aRzA�r xOSPITALUTH FAIRMONT DRIVE <br /> LODI . CA 95240 <br /> 209 334-3411 5/1312011 <br /> Cusror+wHurasen sZ <br /> 2A'DESCRIPTION OF WASTE 28. GErrt7r 1tOA 5 REQgtgA7iQ►I <br /> "MRepulaud McGiraf CONTAINER TYPE 2C.? OF ?p. <br /> Ii.E,FGII DOT-SP 3556 RP.6S - Uasyxte:as Sharps CONTAINERS tlOLlt11E <br /> UM, ftulate4M:Ttatwa#e.n-o.s �� Trans Cart {S9 cu ft) 7f <br /> 6.2.PGII KR9$ - Bio3 a CuR <br /> Ir UNMI Regulidw teditat � Trxa7part Box (4.3 au ft) <br /> p 6a2,PGii no.s, <br /> Cv FE <br /> 6 N232&Regotided Medical Waste,n.o.s, <br /> Cu FI <br /> W UN329t,Re9ol M Medial Vi <br /> � 6.2,POI! Cu F1 <br /> ( <br /> U11=11 Repaiated MedkW W44, <br /> Cu FI <br /> UNMI,Repufated Medkal W35ig, <br /> 6.2,PGII �FI <br /> UN3291Rcoulned Medkal62.PGIJ Yyaste,n.a a., <br /> Cu Ft <br /> RUT Cu <br /> 3,flenerator a eanification-1 hereby dactare It i ttte contanie of thfg I' Vo I <br /> described above i the proper sitong mine,and are dass'fied, �t are luny and acivtatery TOTALS ► -i <br /> are in 8i1 rasp"In proper t10a1 lOr transport aoonrding o aptsrtraifonai and national 8ovarnm I tlo+u" <br /> _ + <br /> ,Print Name <br /> 4.TRANSPORTER t kDDREsS: 3ignaturs Data <br /> 11875 O"e016) 9b5 - 550E <br /> a Q Whita. Rork Rd ApprrrMbie Permit Numbers: <br /> STCRICYCi.E This its a Through 3hipaent <br /> TRANSPORTEXOMF ("GAM ate as de9txiaed above. <br /> Prinveype Name TrRu RW-#3400 <br /> 6,INTERMEDIATE HANDLER 21TTiANSPOATER 2 AOD SS: sere <br /> OaG <br /> N <br /> Phone tl: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:R <br /> ecoo PrintlType Name of n+ed�waste as stescritlad above. <br /> Signature Dale <br /> �, G.[NTEPthdEDIkTE FiAIVDi.E#13/TRANSPOHi'ER 3 ADDRESS: <br /> Phone 1: <br /> APpc�We Aarmit Numbors: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PMtrlype Name <br /> 7.D15CREPANCY INDICATION SiBdsalure Dale <br /> Transferred containers, a. cu ft to: North Salt take, UT <br /> �� [�$A,Dedgnated Fegllty; 88.Alwmate Facility: 8C.Alternate Fedllty: <br /> }� ���{�yy J� //// 8A.Aitarnmre FatlElty: <br /> L �oof�e 1NC Suite C 41 �Aven�Ie Borth tWe/' Y 2 INC. <br /> Sart v.GA 94677 Fresno.CA 93722 North Sah Latce,U7 84054 Yuba City, rA 85991 <br /> 5101502-1781- (5591 273-0994 f 80 t)936- 1555 7S;it.7SIC�5T:8 MOST 23 (5301 755-0585 <br /> J)ALE AWE OR= TSIOST80 <br /> TREATMENT FACI�fTY:1 certify that I have been allthorizad the <br /> received the above IrldiCated'wastes in accordance with the requirement outlined <br /> �ttt l authorization. <br /> agency <br /> cuntreated medical wastes and that 1 have <br /> PrinI f e Name <br /> Signature ___ <br /> Date <br /> �v��.1 <br />