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I►..%• /Sr.t[ceArnpichyaFcral.Ree'N[Enp Rl,k; IN CASEOF EME5FtGENC+CONTACT-SHESTANDARD
<br /> TANDRD MANtFE5T col-to-os•SiV
<br /> fM
<br /> Route . 412 - '-6 912 tT1tL0
<br /> / 8NIB
<br /> 1.'G 'eratoY's fValilB,Address and Telephone Number
<br /> x1 a 3 Y• 1.,5'.R.1- a 1 v J L� p { l $
<br /> 810/LODI MEMORIAL HOSPITAL
<br /> 975 SOUTH FAIRMONT DRIVE
<br /> ...0
<br /> (209) 334-3411 2/3.2/2010
<br /> CusTAv.ER Numern CIOLU
<br /> .7-00-2
<br /> ,. 2 GENERATOR'S REGI$TRATION 9
<br /> 2A.DESCRIPTION OF WASTE 20. CONTAINER TYPE 20. NO.OF 20. VOLUME
<br /> REGULATED MEDICAL WASTE n.o s. CONTAINERS
<br /> UN 3291,PG It DOT-S�1 SS6 1' f1 S - Bt0SVt;Lrt s Stzexys Trans Cart (59 ou ft) CL
<br /> REGULATED MEDICAL WASTE,mes.,62,
<br /> UN 3297 PG lE KRBK - Bi.osv Meme Transgor't Box (4.S Cu ft)
<br /> REGULATED MEDICAL WASTE,nx.s„6.2, �
<br /> UN 3291,PG If
<br /> Ct
<br /> REGULATED MEDICAL WAST!~n.o.s„6.2,
<br /> UN 3291,PG II
<br /> REGULATED MEDIM WASTE,n.o.s.,6.2, Ct
<br /> UN 9291,PG Il
<br /> REGULATED MEDICAL WASTE,n,0.s.,6.2, C
<br /> UN 3291,PG ll
<br /> REGULATED MEDICAL WASTE,
<br /> Ct
<br /> UN 3291,PG II
<br /> REGULATED MEDICAL WASTE.T0=61.
<br /> C'
<br /> UN 3291.PG 11
<br /> Ct
<br /> 3.Generator's Certification:"1 hereby declare that the aonlents of this consignment are fully and accurately TOTALS 0-
<br /> 3
<br /> described above by the proper shipping name,and are classified,packaged,matted and labelleftlacarded,and G:
<br /> are M all respects In proper eydftlon for transp�/p-/acoordl to applicable international and national govern Net regulations'
<br /> Printed/Typod Nam { �� Signatur r Data • '��
<br /> C TRANSPORTER t ADDRESS-. Phone
<br /> (V1s) - 5506
<br /> it Numbers:5S
<br /> 5TERTCYCi.Z �C
<br /> 11875 White Rock Rd
<br /> 7Thix atx 'ErEzrough ffltti)amarrt; Applicable Perm
<br /> Tf3ANSPORTMOERTiIF1i2AM ;, apt iD Ka 1 waste as described above.
<br /> Pr1nt/Type Ntlrrle Slgnaluro Date `,� �
<br /> S.INTERMEDIATE:HANDLER 2/TRANSPORTER 2 ADDRESS: Phone a:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print(Typo Name StgnaturB Dale
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER$ADDRESS: Phone q;
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br /> Print/Type Name Signature SkfeVICE falml
<br /> 7.DISCREPANCY INDICATION CJ A=Wj r; 6069077-M
<br /> Transfeed contain+?rs, �1•�! tx� fk to : Naf�k1 balk Ii Nc, if NIi7lLotli Nrdorial Hosplt&I
<br /> `1'110111 DATE: 2112110 6,21:14 AR
<br /> E]BA.Deslenatod Facility,, 819.Alternate Fadift 8G.Altemale FaClllty:a
<br /> IR 1 D10 to: Al�hdI , �0
<br /> SllllrPlkG"N1 i:-IBRC008II1I3
<br /> STERIGYCLE.INC. 5TERICYCLE.INC. 51 ERIC'YCt E,INC.
<br /> 1345 Dooliftle Drive,Suite C 4136 W.Swift Avenue 90 Nrath i 100 West TKAI {.711.I.ECIE0: 13
<br /> San Leandro,GA 84577 Fresno, CA 03722 North Salt lake,UT 8'4054 TOTAI. VIEW.; 111.240 CU fT
<br /> (515)562- 1781 (559)275- AriN-ORTIZ '6011 936- 1665
<br /> TS31,TS(OST25 TSODS1,22 AUTOCLAVFA Class V lndmration t:,errrrtt#9 ;1111"T 1 Kkt,S 05AAOL7 R>00l al„;:Jr;kxrll
<br /> /� �mNef a kYRI OMMA RX81
<br /> i �>3 8 u t TR `•:I; Jj Yxft! flUhlgtl0 Mail
<br /> TREATMENT FACILITY: I certify that'l have been authorized by the appl e � t e n r !.I;,�,4, k�:11{ UR1,IHg.Cr N%!11
<br /> received the above indicated wastes In accordance with
<br /> ��the
<br /> prequfretneni outlined In that authorization. t .l dpi
<br /> Print/Type Name Sfwu
<br /> S'KIMY(C1011 lype) G1Y 11
<br /> r 1 r! rRfuu Ri,:Sy%i,rNs $h9lps Tills 1 1,9 4(11
<br /> Ilvx-01,)sY r7 ,l A 4n
<br /> (•--!'�J flil.Et4:itY fuX:l7�Fl3I r: 1�bftC(rtBR#Ii
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