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M Stericycle' IN CASE OF EMERGEryC 1-900-234-4051 STANDARD MANIf:L-ST 001.10.06•STo•y„
<br /> •,• rr.a.anar.�ar..R.+�iro�,,fr Route . 31nx-0081 JF
<br /> Gerterfitat"s Name, Address and Telephone Number
<br /> xmfis,r. C'rri a h1SKcyaa �� fF !I llff����l! li
<br /> 13IO/LODI MEMORIAL HOSPITAL
<br /> 975 SOUTH EAI RMONT DRIVE
<br /> LC(VT-:..'CA ....�5��.0..... ....- .............
<br /> (209) 334-2911 1/15/201.0
<br /> cvSvo+aerr NutaCER0 7-002
<br /> Gmr:ft.%xows aeolSrlsanofe N
<br /> 2A.DESCRIPTION OF WASTE 213. CONTAINER TYPF 2C, NO,of 2D, VOLUME
<br /> REGULATED MEDICAL WASTE n. E.6,2, CONTAINERS
<br /> UN 3291,PG It C3L7T S#5 1 511 6S Biagyvtatnx St4bxpv TrAi» Cant (59 cu £C.) Cu
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> w3291,PG 11 MWX Bi.osv!�rt ms Trax iwport 33ox (4.3 eu iwt)
<br /> Cu
<br /> REGULATED MEDICAL WASTE,n.a.s.,6.2,
<br /> UN 3291 PG fi
<br /> Cu
<br /> REGULATED MEDICAL WASTE,n.o.s.,62,
<br /> UN 3291,Pe 11
<br /> Cu
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> UN 3291,PG Il
<br /> Cu
<br /> REGULATED MEDICAL WASTE,n.o.s.,62,
<br /> UN 32911,PG 11
<br /> Cu
<br /> REGULATED MEDICAL.WASTE,n.o.s.,6.2,
<br /> UN$291,PG II
<br /> Cu
<br /> REGULATED MEDICAL WASTE,ao.s.,6.2,
<br /> UN 3291,PG II Cu
<br /> Tsx
<br /> 3.Generator's Certlticatlen:"I hereby dadare that the contents of INs consignment are lully and acxurately TOTALS 10-
<br /> described
<br /> i
<br /> described above by the proper ahlpphv name,and are olassi ied,packaged,marked and labolledlptaoarded,and 1'!
<br /> are In an respects In propezrodition far transport accorirng to appiloable InternaWnat and natlonaf gover ntal egulatlons! ! 7
<br /> printad/ry Bd tJame SEgnature Cate
<br /> CTRANSPORTER 1 ADDRESS: Phonq
<br /> ApplicabletlPermlt Numbers;
<br /> 11:.875 whi to Rock Rd
<br /> :rI`FR3C'ICTrE Thus iZ a Throagh ShiPrannYJ
<br /> TRANSPORT SEWRlUMONABQ'apt9&Ti aeW waste as described a
<br /> PrinVT pe Name Signature Date w V
<br /> 5.INTERMEDIATE HANbLER 21 TRANS RICER 2 ADDRESS:
<br /> 71 Y MICE REE'lPr
<br /> 1 ACC(RIHi 1: 6089077.002 "
<br /> INTERMEDIATE HANDLER/TRANSPORTER CER11FICATION:.Receipt of medical waste as described above. i RIO/Lodi lierrorikl Hospital
<br /> %RVIU.'ELATE: 1115/10 1:03:40 PN
<br /> PrinVlype Name Signature ORRICE 10; ADI
<br /> 6.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: 911PPING 110IX1i1M 1: :ARCO 1,111'
<br /> 1OTAL COLLECTED: 21
<br /> :INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medigat waste as described above. TOTAL UOI.IKl 145,11100 CU FT
<br /> 1111AIK :Y 016 MOM RXBI INIAlzdlt RAI
<br /> Print/Type Name Signature IhIAtNl17':lxif! WioIJLR RXDi +>tJid>!S f<k41
<br /> 7.DISCREPANCY INDfOATION ,a>r PA" RMI (Mau RxOI
<br /> containers, p// (, 1'!t ft to ; Nt�r#h Salt take, U ;dl;,,ta,�� Slfi 0000401 ROI Wolf: !.,Il!
<br /> Transferred 9 6. 7
<br /> $A.Designated Fadltty: UJ 68.Alternate Facility; BC.Ailornate Fasillty; !! sn4,;11,8 i INJI 0MOUR RXDI
<br /> y /,S/)o j]d 70 ,srd�uG RX€11 oiJW7 RXBI IYIHIAir t rill;
<br /> STERICYCLE.INC, SMRICYCL.E.INC. STERICYCL.E,INC. VL
<br /> 1345,Doolhe Drive.Suite C 4135 W,Swift Avenue 00 North 1100 West SWWIY(Dxll type) Qll' Cf
<br /> Sart Uarrdro.CA 94577 Presno.CA 83722 North Sent Lake.UT 840JA
<br /> {5101562- 1781 (559) 2715-090U,_ AN���r�pt� (801)030- 1556 KR65 NoSy,le-s Shat i1's Trans t 5q am
<br /> TS31.TG(09T25 T—.(6s-r 22 A11�OG _ M � �Et7g��t 1iC 121 I'lwow,xutictl BOX-0105y ?J1 15 .1m
<br /> !� t I
<br /> TREATMENT FACILITY: I certify that I have bean alllhOTized 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 /> Print/Type Name _Slgnaturt3 � � _ Date
<br />
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