Laserfiche WebLink
MEDICAL WASTE TRACKING FORM NUMBER <br /> !:4,4111, Stericyciv IN CASE OF EMEAGENCY CONTACT:CHEMTREC 14=.424.4= STANDARD mAmFEsr aoi-*or)-5TD <br /> • P,►•re-W-Apla Route #: 413 3a CUSTDMER NO.21132 MUC00JAY05 <br /> 1.Generator's Name,Address an7dTelephone Number <br /> BIO/LODI MEFORIA' b HOSPITAL <br /> 975 SOUTH FkIRMONT DRIVE <br /> LODI. Cit 95240 <br /> (209) 334-3411 6/1012011 <br /> cx a Ntataat $;r. Q n 7 7_ GEwuumas RFcasr uw s <br /> 2A-DESCRIPTION OF WASTE 2a. CONTAINER TYPE 2C No_OF 20. VOLUME <br /> UMj CONTAINERS <br /> 6.2,PH Regulated MOil��Mpp,pp zp.65 - BioSystettrs Sharps Tracts Cart (59 cu ft) t.FL <br /> UN3291,Regulated Medical Waste.mos., <br /> 6.2,PGII ME - Bio3v3te= Tranzport Sox (4.3 cu ft) Cu� <br /> Q UN3291Regufated Medical Waste,n.o.s„ Cu Ft. <br /> 62,P61i <br /> CUN3291,Regulated Medical Waste,n.o.s., <br /> M 6.2,PG II Cu Ft. <br /> W UN3291Regutated Medkai Waste,n.es.. <br /> IZ 6.2.PGII Cu FL <br /> UN3291Regulated Medlral Waste,n,os„ <br /> 6.2.PGli Cu Ft. <br /> I U6.23291 Regulated Medical Waste,n.o.s„ <br /> Cu Ft. <br /> UN3291,Regulated Medical Waste,n.e.e., <br /> 6.2,PGII Cu Ft. <br /> RXBI dq 7,52- ouFt. <br /> 3.Generator's Certification:'I hereby declare that the contents of this consignment are fully and accurately TOTALS �O Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and labebted/placarded,and <br /> are in ail respects in proper CO dition for transport aetordUV to applicable international and national gwem mai r ulattorm. <br /> T �Prfntek nVW Nance Signature f Dale to•i <br /> 4,TRANSPORTER 1 ADDRESS: <br /> � Phone 16) 995 w 550E <br /> y Applicable Permil Numbers: <br /> rt 11875 White Rock Rd Thier i!s a Through Shipment <br /> N STERICYCLE <br /> IL a TRANSPORTE FIQAT R ih l vrasta as desenbed Trans Reg.#3440 <br /> � /I <br /> PrinYrype Name i Signature Date 40rr <br /> 5.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: V I phone N: <br /> a� Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> n G.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone p: <br /> Applicable Permit Numbers; <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrinVType Name signature <br /> Data <br /> 7.DISCREPANCY INDICATION Transferred '�- containers, cu R to : Fresno, CA <br /> Transterred_tL—containers, .*Z cu ft to : North Salt lake, LIT <br /> r ❑6A.Das]Wu tad Feeiltty: 8a.Altemste Facility: BC.Alternate Facility: U 80.Alternate Fad ty; <br /> cs CYCfte! V",e��YW gg C INC. Borth <br /> Ri CC �����C. GY ,lNG. <br /> 3 e00 G 41 �lvenue o iT3i7 ti�ran Leant 4 Fresno. 722 'w J Salt Lake U� P4(154 Yuba Ci V.`A 9598t <br /> (51171562-1781 (5591275-4994 (sail 036-1555 (530 755-0585 <br /> 6 <br /> u TS31.TS(OST25 TSIOST22 Class V IndneradDn PSM09f TSIDST 80 <br /> ALE ANNE ORTi <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 L=Irement outlined in that authorization. <br /> Print/Type Name Signature Date <br /> i <br /> ORIGINAL n*Rrktar 4Std MAN <br />