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<br /> Rouva f: a MDRC00 11:SX
<br /> i.Generor's Name,Address and Telephone Number # #
<br /> 1310/LGDI MtMORIAL HOSPITAL
<br /> 975 SOUTH• FAI RMONT DRIVE
<br /> 2 X04- 0413 —1/29/2010
<br /> CUSTOMER NUMBER on, GENERATOR'S 1`1EelSTRATION 9
<br /> 2A.t?E SCRIPTIDN DF WASTE 28, CONTA4NERTYPIE ,O2r.. VOLUME
<br /> REGULATED MEDICAL WASTE,n.os.,62, CONTAINERS
<br /> UN 3291,PG II OT-SP 13556 KR65 - BS.oti iGtr= & s Trate Cart: (59 OU ft) Ct
<br /> REGULATED MEDICAL,WASTE,n.o.s.,62,
<br /> UN 3291,PG 11 HRBX - BioSve;teaas Tranerpaxt Box (4, au ft) Ct
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, v
<br /> UN 3291,PG Il Ct
<br /> REGULATED MEDICAL WASTE,n.o s„6.2,
<br /> UN 3291,PG 11 Gt
<br /> REGULATED MEDICAL WASTE,n.os„6.2,
<br /> UN 3291,PG It CI
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> UN 3291,PG 11 Ot
<br /> REGULATED MEDICAL WASTE,
<br /> UN 3291,PG II C+
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> UN 3291,PG II
<br /> Cv
<br /> AXBI 56
<br /> Ce
<br /> 3.Generator's Certification:It hereby declare ttial the contents of this consignment are Cully and accurately TOTALS
<br /> described above by the proper Shipping name,and.aro olassHied,packaged,marked and labelledAAacanfed,and Ce
<br /> are in all respects In proper oondition for transport according to applicable International and national governmental regulations'
<br /> Arinledfryped Name Signature ~ 2 Date
<br /> 4.TRANSPORTER f
<br /> ADDRESS—Phone
<br /> ff'��",. ApPtio�bl�PermiC�l�bers:S60G
<br /> ` 11875 %hit-ft Rock Rd
<br /> t;TE'<tTCY�G£ Thj* iTh cough ah ipsucnt
<br /> TRANSPORTEKhQrjfjjIF LQAUQ l @4Wt t*1 401 waste as described above.
<br /> PrinVTypo Name Signature Dat*
<br /> 6.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone p;
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as descr€bed above. KNIQ RFC!:IYr�.
<br /> 5o8sOT7 002 `
<br /> PdnU7ypo Name Signature >,CC()tlFfi f:81D/Lokli ifewrld Hospital
<br /> G.INTERMEDIATE HANDLER 3 1 TRANSPORTER 3 ADDRESS: SERVILL liATf:: 1179li0 6:531-56 AN
<br /> ',lI;I4ti:NG 7111:t1Y[HT 1: HDRL'OOSXSg
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recolpt of medical waste as described above.
<br /> TI11AL WA-KIEB: 8
<br /> Prinl/Type Name Signature IOTAi 34.560 LU F1
<br /> 7.DISCREPANCY fNDICATION ��j/ // ;Y4i,961 fixor OUM5 Rll[t}I itU�rd Rif,;
<br /> Transferred. c:antainers V1,96cU It to : Nortli Sall:lake, L :�r'Grt'it R%BI I)OfiilpEA RKB1 :rrrrnat l:rt1:
<br /> eA.Designates Faouu t1?At>OKA Rat OOAooxB R!(BI
<br /> ❑ y: 9B,Altornele Facility; SC,Aaernate Fac►Ilty: )
<br /> $ IR . . `— 1d//O SEr7ifWlYiC�wl IYPe1 QIY V[
<br /> STERIGYCL.E. NC. ST•ERIGYG4E.INC. �t�l�Y�1� fNG.
<br /> 1346 Doolittle Drive.Suite G 4135 W+ .'w tAvlynuc� 0 ort 1 00 Wept Rz8' ^I,.,...,,••,I cal BOK Iii�iy A
<br /> San Leiindro.GA D4677 Fresno.CA 03722 !North S;i t lake,UT 34054
<br /> 1`6101562- 1781 (658)27'6.0884 (B0i)936- 1555 ilii 1+R k1'fltt'UI1fNf 1: F'DtlCrlt19ksE
<br /> TS31.T9ffJ9,T25 TWST 22 Cris%! porn-i'a
<br /> TREATMENT FACILITY: t certify that I have been authorized by the applicANA n p r a e edical wastes and that I have
<br /> received the above(ndlCated wastes In accordance with the requirement nutiined-in that authorization.
<br /> PrintrWeNamo 5tgnaiure - - -- pate
<br /> TREATMENT FACILITY
<br /> i
<br />
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