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' f41E1)tCAL WASTE TRACKING FARM NUMBER <br /> StericycteIN CASE OF EUFRGEkCV CONTACT:CMEWMEC 14MA24- W 51ANOARt)llugl EST Op1.140�CiD <br /> "Maki ftW`b&id'Q' Route #: 413 14 CUSTOMER ND.21132 M PIC1)(LAVA 4 <br /> 1.Generator's Name,Address and Telephone Number <br /> BIO/LAM MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE Jp�j <br /> L-ODI . CA 95240 <br /> (2491 3'--"4-3411 5/27/2011 <br /> Cusrowau Ntnesm A n R fa rr,7—n i l? Quamm s ftmanumN a <br /> 2A.DESCR"ON OF WASTE 28. CONTAINER TYPE 2C. NO.OF 2A VOLUME <br /> U2.PGII Regulated Medial Waste n.o�s CO►QAptEt1S <br /> 6.2,P'GII ppT.1Pi35� fCRIiS - SiaSystcttxt: Sbnrp� Trete: Cert (S9 ett ft) �� <br /> Gu FL <br /> UN3291,Regulated Medial waste.aa.s., <br /> 62-PGII MBB - Bio3yst=s Transport, Bax (4.3 vu ft) <br /> Cu FL <br /> M UN3291,Regulated Medial Waste,n o.s., <br /> O 6.2.PGII Cu Ft. <br /> C UN3291.Regulated Medial Waste,no.s.. <br /> 13; 6.2.PGII t Cu FL <br /> W UN3291.Regulated Medlad Waste, <br /> LU <br /> 62,PGII t:u Ft. <br /> UN3291,Regulated Mediaal Waste,mo.s., <br /> 6.2.PGII <br /> Cu Ft. <br /> UN3291,Regulated Medical Waste.n,o.s.. <br /> 6.2,PGI I CU Ft. <br /> UN3291,Regutated Medlal Waste,n.os., <br /> 6.2.PGII <br /> Cu Ft. <br /> RBBT 30', <br /> Z F <br /> 3.Generator's Certlfleatlon;"1 hereby declare that the contents of this consignment are fully and accurately TOTALS ► 9 6—y4,FI. <br /> described above by the proper shipping name,and are classified,packaged.marlred and labefteWplacarded,and <br /> are in all respects in proper nditlon for transport a000 ing to applicabkr IrfternaUonal and national gnvem ntaf r lations' I <br /> ^ IPrintedfrypedNam Signafurer Date f <br /> cc 4.TRANSPORTER 1 ADDRESS; Pnone1;915) 985Lu <br /> - 5SOE <br /> 11875 White Rork Rd Applicable Pernrif Numbers; <br /> e ¢ FXI This i= s Through Shipment <br /> CRL a TRANSPOt al iVS waste as desc Traf s.R 240QQ <br /> ~ Pdnllrype Name ig Date <br /> S.INTERMEDIATE LER /TRANSPORTER 2 ADDRESS: Phone t!: <br /> Applicable Permit Numb <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Pri <br /> ntllype Name Signature Date <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone tt; <br /> gg Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrInUTypa Warne Signature Date <br /> 7.DISCREPANCY INDICATION L� �y' <br /> Transferred containers, 30 T cu ft to : North alt lake. LIT r `r1 ,817 <br /> 9A Oasignated FacRy: IS.Altemate FadIlly: Aftarnatb Fadley: Ej 8D.AftwaW Facility: <br /> v CYC INC. YC INC. 7'�Ri�ycc C. 'CY%E.INC. <br /> 3�i00&e%r ve_Suite C � Stn Avenue �4 forth 1 West ���t 3n Ur <br /> F Sara)Leandro.CA 94577 Fresno.CA 93722 North Salt Lake,UT 84054 Yuba Citv.CA 95981 <br /> 05101552- 1781 (5591275-0994Sf�9��/ (,801)936- 1555 i(53©1755.0585 <br /> w TS31.TVIDST25 TV05T 2? Class 1r lnanem on Permit#91 TS/OST so <br /> 0"pANNE ORM <br /> VEn <br /> TREATMENT FACILITY:I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> received the above indicated wastes in accordance with the-requirement outlined in that authorization. <br /> PrinVType Name Signature Dale <br /> «19]aI..14 <br /> ORIGINAL rFtl3eltarr5tlE4 dd 95 lb, <br />