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u.., , ,.6 ,IU:Y-it-/UII tVitI ) 12: U5 <br /> 06/17/2011 FRI 12: 14 FAX I': dfl2 <br /> 5 ' IH CASE OF EU6fMEUCY CC)NTpCr:CHEWMEC 1.8*4x4•B�pO 14002/028 <br /> arnnuvl►iuw�mre�r eot•�oQe-��o <br /> Raetta 413 .y CMTOUr;R No.21132 MLiRC(} A 1 <br /> 1,Generator's Name,Address and Telephone Number ] O -L <br /> SIO/LODI MEd'iQRIAL NOSAI T AL <br /> 975 SOUTH FAI RMONT DRIVE <br /> LODI . CA 95240 <br /> 2091 334-3411 5/20/20 .1 <br /> CtnsoEM Nvara�n <br /> '7—r1 •s GFt�ptTpq g RFCpswmaN 0 <br /> 21LgESCRIPTIONOFWASM 2B. <br /> CONTAIHERTYPE 2C.Nt7.Ofi 2O. YOWfaE <br /> 6.2pC,]ll•R�teti 1AedialYiraSte mos, CONTAItrERS <br /> OOT SP no4., IiRSS - Sia5psteax: Shaxps Trans Cart (59 cu Et) <br /> ��Ili Regulated fAeQrpt l+►raste.n.o.s., Cu Fa <br /> »T — Sio3ywt=& Train!, Box (+�.3 cu ft) <br /> � 6?Poli�t�brattier Waste,ao.s.. <br /> i1N3291 f3epulated Medial lar Fr <br /> 6.2.PGII lA/asle,R,os.. <br /> Cu F, <br /> UN3 11 Repu Medical Was,,r,.o.s,. <br /> Cu F! <br /> 0 62Poq Rmteld Medical Waste,n.0j" Cu F, <br /> Wi3291.RLTUlatod Medkal Waste,n.o.S.. F_ <br /> 8Y.PGfI <br /> Ulyd2�91 Regulated INett1W Waste,n.o.s., cup <br /> RSBI F <br /> 3,deneratofa Certttlrstian:'I hereby deClare that the caateras of this cons! any}�and acwretaiy TOTALS► <br /> described above by the proper"p4V name,and are dasslfied,Packaged, <br /> are In all respects In proper on for transporl ar:oord to � �,rnaric8d and iabelledlplacarded,end +� Cu F <br /> f aWkabte international and natlonat gone ental regulaftw.' <br /> I ` Ydntedfr ad Name <br /> e,TRANSPORTER t ADDR Signahrre Dale ' <br /> �6eT-9i6) 995 — 550E <br /> S3.2@75 White Roel: Rd F-1ThMPe Permit hun+bera; <br /> WEIRX.CYCIx is is Thvouah Shipment <br /> TRANSPO�F a wasteasdescribedabove. <br /> Trrtns Ttet+#3 <br /> PrtnVType Nerne Signature . <br /> S.INTERMP[31A7E HANDLER 2 I TRANSPORTER 2 ADDRESS: Dare <br /> rc Phons F <br /> Applicable Perm*Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:R <br /> � tsO*of medical waste as descrtlaed$s:ovo. <br /> PMVTypo Nam Signature <br /> B.tWERME WTE HANDLER 31TRANSPDRMR 3 ADDRESS: Data <br /> Phone M; <br /> w AP*abte Perm*Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION;Recaps of medical waste as described rabm. <br /> x <br /> PMVType Name signature7.DISCREPANCY INDICATION /_ )] Dale <br /> Transfe ed 1_ <br /> A V alriiainer5, Io I l� Cu I to ; North Salt Fake, U7 <br /> ❑aca.I .d r <br /> 88.Alian*ts FatAt►r• 8C.A tsmats Fsa ft so.Attrernats FacHrly <br /> tf / <br /> a , 100n <br /> C ING UIL0 R C AAIINNC. , �ab an Lro 84 C �5r$ 3722 ue ° i�••�C I%Cyfrr 'INC. <br /> W (5101562- 1781 5 1275-0994 orth alt La U 89054 CIN.CA95991 <br /> T531.T&OST25 TSIOST 22 (80 t)938-1555 (530)755.0;S5 <br /> I Glass Lr)ncineration Permit#91 TSdOST 8Q <br /> � E ANN��t��T�Zf ��lZ <br /> TREATMENT FACILITY:I certlty that}have been authorxed by the applkable�7 LE ANNE state agency to accept untreated medical wastes and that I have <br /> remove hove indi�tte@ I ff fs In accordance VAth the requirement oLrllined In that authorization. <br /> Frftlyim me 2 4 2Qi <br /> signature <br /> Date <br />