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QW <br /> MEDICAL WASTE TRACKANG FORM NUMBER <br /> 0*• Sterlcycle' IN CASE OFEMERGENCVCONTACT:CHEMTRECI4D424-WW STiwoARnMAraLFTsroot•taoo-sro <br /> • ►1bi�"'r'�'d+ Route #-. 413 -10 CUSTOMER NOL 21132 MPRCO DAX.Tq <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN. Gavle noses <br /> BIO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI . CA 95240 <br /> (2091 334-3411 613/2011 <br /> CtrsTOMM NUMMM 1A n P Q n GEnfMmn•s REo:tr"n= <br /> 2A.DESCRIPTION OF WASTE 28• CONTAINER TYPE 2C.NOL OF 21% VOLUME <br /> UN3291,Repulaned Medical Warts n. s. coM EAS J` <br /> 6.2,PGII 0510111,194 i19SE IIRGS - BioSystems Shazps Zrans Ca=t (S9 cu ft) UX Cu FL <br /> UN3291,Regulated Medical Waste,ng--, <br /> 62.Poll ISRB% - Bio3ystems Tratrloport Box (4.3 cu ft) Cu FL <br /> UN3291,Regul;aM Medical Waste.n.os., <br /> 62,PGII <br /> Cu FL <br /> Q UN3291,Regulated Medical Waste,n.o.S., <br /> 6.2,PGII Cu FL <br /> W UN3291,Regutaied Medical Waste,nx-S.. <br /> Z 6.2,PGII <br /> I Rtgulated Medial Waste,n.o.s., <br /> 6Cu Ft. <br /> NM <br /> Cu FL <br /> UNMI,Regulated Medical Waste.nA.s., <br /> 6.2.PGIr Cu FL <br /> UN3291,Regulated Medkal Waste,n.os., <br /> 6.2,PGII Cu FL <br /> RHBI ,57i Qu F <br /> 3.Generator's Certification:N hereby declare that the contents of this consignment are fully and aomrately TOTALS lip, Cu FL <br /> described above by the proper shipping name,and are Classified,packaged,marked and labelled/placarded,an0 <br /> are In all respects in proper condition for transport according to applicable international and nalionat governmental reguiatio s' <br /> 1PrintedrrypedName Signature Date <br /> A.TRANSPORTER 1 ADDRESS, Phone0(916) 9e5 - 55()e <br /> Applicable Permit Numbers; <br /> Q 11875 White Rock Rd � <br /> N Lam.! <br /> STERICYCLC This is a Thtcough Shipment <br /> K a TRAN$PORTE 113A t to <br /> 6t00 waste as described above. T Tara Rem#'3400 <br /> Print/Type Name A1/l Signature Date_fll A Y <br /> 3.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone A: <br /> ns Applicable PWft Numbers: <br /> tun <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receiptof metrical waste asdescrlbed above. <br /> PrinVroe Name Signature Date <br /> a.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone#: <br /> Applicable Permit Numbers: <br /> a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrintfType Name Signature Data <br /> 7.DISCREPANCY INDICATION Transferred containers, <br /> (�. Du ft to : Fre}no, CA <br /> z Transferred containers, 2 cu ft to. North Salt lake, UT I <br /> r <br /> []$A.Designated Facility: [POB.Alternate FacMir.Vva <br /> 1111c, <br /> Attemate Fadltty: jj BD.Afteff to Facility: <br /> v <br /> STERiCYCLE.INC. STERICYCLE.INC. STERICYCLE,INC. STERICYCLE,INC. <br /> 1345 Doolittle Drive.Suite C 4135 W.Swift Avenue 90 North 1100 West 1812 Starr Dr <br /> Sari Leandro.CA 94577 Fresno.CA 93722 North Salt Lake.UT 84054 Yuba Chv,CA 95991 <br /> 211 (5101502- 1781 f 5591 275-0994 (801)938-1555 (530)755-0585 <br /> T531.T fw-25 Class u Incirw tion Pvrn,+*01 T.90ST 9D <br /> C NE ORTIZ <br /> I Lu TREATMENT FACILITY:I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have <br /> }- received the above indicated wastes in accordance with the requirement outlined in that authorization. <br /> Print(rype Name Signature Date <br /> 112 a <br /> ORIGINAL II <br /> _._�� - - - --- — -- �- —ratRFeldStd rr1..i■ _ • <br />