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ILA uaLu/ 1A131 duly-I I-LUII trKI) 16:05 P. 025 <br /> 06/17/2011 FRI 12: 21 FAX 0425/028 <br /> Ny bncm�riC4 rav+rca.-..wa ,r..w..,4Mw <br /> r �,,...�r"r tom` <br /> i.Generator's Name,Address and Telephone Number I r <br /> ATT�;: Gaq,4 <br /> LODI MEMORIAL HOSPITAL <br /> 975 S FAIRMONT AVENUE <br /> LODI. CA 95240 <br /> (2091 339-1668 1/12/2010 <br /> CUMMIM NUMBER—60924$2-002 aENERAMA a pM rtE(fTMTof <br /> 2A.DESCRIPTION OF WAM 20, CONTAINER TYPE 2C.NO. Zia <br /> REGULATED MEDICAL WASTE,n o.s.,6. VOLVUE <br /> UN 3291.Pa II TS14- a 14-(path) 44 Gal Tub (5.9 cu ft) CONTAIN 5 <br /> REGULATED MEDICAL WASTE,u.s.,0, //,7 ./ <br /> UN 3291 PG 4 T821-(Sio) / T815-(Path) / iS-(Chemo) 2 Gal Tub (2.7 <br /> Q REGULATED MEDICAL WASTE,n.o.s.,8 n 2 a, <br /> Q UN 3291.PG 11 1849-(Bic) ! TL'4 9-(Path) / TY49-(Chemo) 37 Gal Tub (4.9 <br /> ~Q REGULATED MEDICALWASTE.a.o.s.,62. T835 - 26 Gal Tub (Big) (7.5 au ft) C, <br /> w ON 3291 PG If <br /> W REGULATED MEDICAL WASTE,ao.s.,6.2, Cu <br /> W UN3291.PG II TFS1 - 90 Gal Tub (Bio) (12 au ft) <br /> REGULATED MEDICAL WASTE.n.os.,6.2. Cu <br /> DN 3241.PG I1 TB64 - 48 Gal Tub (Bio) (6.4 cu Et) <br /> REGULATED MEDICAL WASTE,n oA..6.2, <br /> CO- <br /> UN 3291,PQ It qT96q9696 r a] (17.78 ft) <br /> REGULATED MEDICAL WASTE,e.e.s..6.2, <br /> UN 3291.PG It ST64 - 64 Gal Tub (Sig) (9.67 au ft) <br /> ..79—M74A <br /> S.Generator's CertlIWWon:*1 hasty dedare chat the Oontsnta Of this consignment are tufty and a0Cpr8iBly TOTALS � 5 j� <br /> de=U*d atwve by the proper shipping name.and are dassitied.packaged,marked and tabett 1acarded.and Cul <br /> are in all respMa.in proper conenon for Vanswri according to applicable Internatbnel and national govemmentall lau s` <br /> 1X1P_',1WyP0d Name aturs ate <br /> L.TRANSPORTER 1 ADDRESS: <br /> Phon <br /> e 9 11975 White Rock- Rd <br /> Applica a faermR gas <br /> 5506 <br /> �€g 5TERICYC.LE Th 15 i% a Through SEaigraeet <br /> 4 nx <br /> TRANSPORT GERM NUF)dWot E1SAdW t waste as described a <br /> Prlr,rArype NameSignature Date 1 1 L' LU <br /> S.INTERMEDIATE HAN FA 21 TRAN RTER 2 ADDRESS: Phone#- <br /> JI Ur <br /> Appllcebte Permit Numboraa <br /> INTERMEDIATE HANDLER ITRANSPORTEA CERTIFICATION:R t <br /> eoe� 01 medical waste as described strove. <br /> PrinVPAm Nama Signature Date <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone r: <br /> Applicable Pw.Il Numbers; <br /> INTERMEDIATE HANDLER ITRANSPORTER CERTIFICATION:Rewipi of medical waste as described above. <br /> PMVTYpe Name signature pare <br /> 7.DISCREPANCY INDICAITIDN <br /> Transferred 1 containers. J'7 cu I#to : North Salt lake, LIT <br /> i .Deslgnetep ftel9ly: 88.Attemelg Fsdliry- BC.Altsmsla facility; eD.Attenw Facllky <br /> STERICYCLE.INC. STERICYCLE.INC. STERICYCLE,INC.Dkv STERICYCLE,INC. <br /> 13441 Doorltde Drive.Supe C 4135 W.Swift Avenue 90 North 1100 West 1512 Starr Or <br /> • � San Leandro.CA 94577 Fresno,CA 93722 <br /> North SaitLake,UT 84054 Yuba C"�y CA 95991 <br /> (510)662. 1781 (558)275-0994 (601)938- 1555 (530179q�•t7170 <br /> E T531.TS(QS12'i MOST 22 G V 1 n P-B,P-146 <br /> SPitL14� 6t <br /> + TREATMENT FACILITY:I certify that!have been authorized by the applicable state agency4o accept untreated medical wastes and That 1 have <br /> received the above i d es In accordance with the requirement ouui in th rization. gp <br /> PrinViype Narne Signature - Date JAN 13 2010 <br /> nor.7 Alr <br /> zr cI <br />