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_ <br /> 00 MEDICAL WASTE TRACKING FORA NUMBER <br /> ! <br /> -0041 hiSterk-yde- <br /> IN CASE OF EMERGENCY CONTACT:CHENMEC 1.800-424-8300 STAIYpArip A!AlJIFES r o0t•sq-104)&STD <br /> Route 41? -9 CUSTOMER N0,21132 1+��1�C:Ilf1 <br /> 1.Generator's Name,Address and Telephone Number <br /> XTTN: Gayle Moses <br /> SIO/LODI MEMORIAL HOSPITAL, <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI . CA 95250 <br /> (209) 334-3411 6117/2011 <br /> CUSTOMM NUUM i�(1R f17�]-t1n GDr>:AATotrsRrotmRAnom <br /> 2A.DESCRIPTION OF WASTE 2B. CON'TAMER TYPE 2C.No.of 2D. VOLUME <br /> UNMIU i--t3 CONTAINERS <br /> 811RM 5 e1 Y.P.63 - SioSpstcurs n„harps Traas Cart (59 cu ft) <br /> UN3291,Regulated Medical Waste,n.o.s, Cu FL <br /> 6.2,PGIl HRSB - Bio3ye:te:ma Transport- Box (4.2 cru ft) <br /> M UN3291,Repulated Medical Waste,n.os., Cu FL <br /> 0 6.2,PGIi <br /> ~ UN3291, ufated Medical W <br /> 6.2,PGII este .o-s., Fl <br /> Z UN3291,—Rd gulated Medical Waste,st.Os.. Cu Ft. <br /> tZ 6.2,PGII <br /> UN3291,Regutated Medical Waste,mo.s., Cu FL <br /> U.PG II <br /> UN3291,Regulated Medical Waste,n.e.s.. Cu Ft. <br /> 6.2,PGII <br /> UN3291.Regulated Medical Waste,n.o.s., Cu FL f <br /> 6.2,PGII <br /> aa Cu FL <br /> R.gHI �d• n.F, <br /> described shave bby the <br /> 3.Generator's y loil:9 hereby declare that the Contents of flus consignment are fully and accurately TOTALS f J7•b <br /> he pproper shipping:name.and are classified,packaged,marked and labeftedoacarded,and Cu FL <br /> are In all respects in proper 6ition for transport according t applkabre international and national govern ental regulation&- ` I <br /> ¢Printed/typedIName Signature Data v'� �l <br /> 4.TRANSPORTER 1 ADDRESS: PhOne lt:p 16) 985 - 550E <br /> 11875 White Rock Ftc3 � Applicable Permit Numbers: <br /> IK 0 <br /> 2 a3'I`ERICYCLrE �[ Thiz ie a Through 3hwpment <br /> N <br /> a od[ TRANSPORTER .apt iJd I waste as described above. Trans Reg.#1`3444 <br /> ~ PrinUlype Name V4 M B14—Signature Das '� <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phoria tI. <br /> Appliciae Permit Numbers: <br /> S INTERMEDIATE HANDLER 1 TRANSPORTER CERTIFICATION:Receipt or medical waste as descrltted above. <br /> PdnVWo Name Signature Data <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone N: <br /> Applicable Permit Numbers, <br /> a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described agave. <br /> �z <br /> — PrIn0;ype Nemo Signature Date <br /> 7.DISCREPANCY INDICATION Tramfrmd Optifti8fr1LC5 ft to : Fresno, CA <br /> TransferredR I containers, Cu ft to : North Salt lake, EST <br /> 8A Dad noted Fecip� * I=Alternate Facility:r p t1r: aB.Artersrata Faep eD.Attemate FaeGky: <br /> Q CYC E l(VC. �RICYCLE.INC STERiCYCI E INC. STERiCYCLE.INC. <br /> ool a i:?nve.Suite C 1 W.Swift Avenue 90 North 1100 M-1 1612 Starr Dr <br /> San Leandro.CA 84577 Fresno.CA 93722 North Salt Lake UT 84054 Yuba City.CA 96991 <br /> (510)592-1781 (5581275-0994 (8011936-155ty x:530)755-0585 <br /> TS31.TSICST25 MOST 22 Class b)nadner,0on Pemrtit;91 TSIGST 8Fi <br /> D&E ANNE ORM <br /> oW TREATMENT FACILITY: I certify that t have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> t- received the above indicated wastes in accordance with the requirement outlined In that authorization. <br /> Print/Type Name — Signature Date <br /> LIA d1-X4��2 <br /> ORIGINAL. <br />