|
�� ►`W W„f Rem.KeA+ctn9 M,k' ...,..�..�... ..... ........�........,w., ��-.,.,,,,...y,..W... ..... _...._.................. ...vv-u,u
<br /> � xt�u'� �• r.�� M�RGL7t7$3aXl•
<br /> I.Geperator"s Name,Address a`ndiTelephone Number
<br /> ATTN: Gvl.e MoseN
<br /> R
<br /> IO/LODI MEMORIAL HOSPITAL
<br /> 9` -D75 SOUTH FArryIRIAONT DRIVE
<br /> LO I. ...-
<br /> .r CA 19524 0
<br /> 2091 334-3411 205 `2010
<br /> Cunomen NUMBER r GEHEnATows RcotsvRATtoN 0
<br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO.OF 20. VOLUME
<br /> REGULATED MEDICAL WASTE,mc.s.,6.2, CONTAINERS
<br /> UN 3291 PG Il ❑OT-vim'13556 KR65 - ZjoS maty Sh4x jw Trans Caxt (59 cu 1r C) Ct
<br /> REGUf ATED MEDICAL WASTE,n,0-s..6,2,
<br /> ON 3291 PG 11 KR13X Siouvstams Trari+port Sox (4.3 au ft) Ct
<br /> REGULATED MEDICAL WASTE,
<br /> UN 3291,PG 11
<br /> CL
<br /> REGULATED MEDICAL WASTE,n.o s.,6.2.
<br /> UN 3291,PG II Ct
<br /> REGULATED MEDICAL WASTE,n.o.sti6 2
<br /> UN 3291,PG II Ct
<br /> REGULATED MEDICAL WASTE,n.mj.2,
<br /> UN 3291,PG II -CL
<br /> REGULATED MEDICAL WASTE,n.o.s.,6.2,
<br /> UN 3281,PG It w.
<br /> REGULATED MEDICAL WASTE,n.o.s.,6,2,
<br /> UN ML PG fl
<br /> Ce
<br /> AH$1
<br /> 3.Goneratoes Coniflcattotr"1 hereby deefam that the contents of this consignment are lady and accurate)y TOTALS ►
<br /> described above by the proper shipping name,and are classifled,packaged,marked and fabelfed/placarded,and a
<br /> are in all respects in proper condition for transport according to appticabie intematlonal and national governmental regulatlons'
<br /> Prints ped Name cr Signature Dale
<br /> 4.TRANSPORTER 1 ADDRESS: Phone y�Rq: pA 55''
<br /> Applica>tiI� 1ml?lQumbers:55 d 6
<br /> 11875 fd it-e Rock Ind
<br /> 5TT RICYC'"L, 0 Thiry 11711cough Sha-pssent
<br /> TRANSPORTEjl%r,@RT)FLl T@19 hPaTMpt g gal waste as described a
<br /> Print[lype Name Signature Date
<br /> 5.1NTERMEDIATE HANDLER 21TRA S]PORTER 2 ADDRESS: Phone 0:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PrinVType Name Signature Date
<br /> 6.INTERMEDIATE HANDLERS J TRANSPORTER 3 ADDRESS: I D.'.4'
<br /> 51:1tVI1T.RElI:1PlXCUT
<br /> 002
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. 01011.vl 1. mond 10SP
<br /> tit0ll.Nl; Hriwrlxl Ilaspit0l
<br /> SENUiFt IIAIE: 215114 7:19:29 All
<br /> Pr1nVPAm Name Signature
<br /> UI int 10: A€AB
<br /> 7.DISCREPANCY INDICATION
<br /> �111f'PiHti 11L1ClkIEII( w: IIE)IiCOUBt.>n
<br /> Transferred _ ogntainens, ,a Ou It to : N0111-1Salt lake. L
<br /> 8A.Derignated Facility; SB.Alternate FacNrty. 80.Alternate Faollfty: TOTAL C41l.EGTFO: 19
<br /> TOIV W LK: 82.OW EU FT
<br /> STERICYCLE,INC, STERICYCLE.INC. J ICY �� IdC, Ir0OC) �:,%I) WOOD PAI NINA'(,RXM
<br /> 1345 Geolbe Drive.Suite C 4135 W.S1Mft Avenue �I�attl7 i�RQ Well l,>,lnl[t +I un�or�E RY01 �x�j,tu:r !i>,Ol
<br /> San Leandro.CA 94577 Fresno.CA 83722 North Saft Lake,LIT 84054 ;;qo aw-Ii WI ;.,e,,nf: r,ratl
<br /> (5 10)562- 11781 (559)276-0994 (801 l 036- 1555 iiol IX on. AXBI ;,1ra1p!N.I
<br /> TS3t.TWOST M TWO ST 22 �'�4s� n t�c�as� 4lefrnut 61 r ��au';°'t'lli lroldlr�t.1 fl>8l .IA,P 1 srin
<br /> D E:�. A KN E ORT
<br /> 1 I(1UhiK3l.6 R][U l a1hU4l.4 R+Il I :;,i'a a?`. r�f!
<br /> TREATMENT FACILITY: f certify that I have been authorized by the applicable state agency to accept untreat
<br /> received the above indicated wastes in accordance with the requirement outlined'in that authorization. Vol
<br /> _ SIINWRYSCoril lype} 4TY G
<br /> PrInVType Name _ Signature
<br /> t11411 P{rinNi.r„f!cal l3ox-Biusy .9 A2.6a
<br /> ,> r P� y N-I IUFfiY nt1HEHT if: P01(Et3091 x
<br /> 101A1. [lE1.IUF1ii:p ITEIG4: f
<br /> TAPATARPNIT PAPAI Iry Tvf1f nT
<br />
|