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,« VdLC/ I ttRe dum-I I_ZUII (FN1) 12: 0§ P 019 <br /> 06/17/2011 FRI 12: 19 FAX 019/028 <br /> tr to• stet te' <br /> i ��RW IN CA$t:or EMERGENCY CONTACT:CREMTREQ11Ve ...n+w+nv�naaRrnw wn iy y aw <br /> Monte #: 43.3 B $aa-azg-s�o�o'"'"" pR�;D080FG <br /> 1.Generator's Name,Address and Telephone Number <br /> SIO/LOBI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA. 95240 <br /> 1209} 334 -3411 3152010 <br /> CUSTotrER NUMBESt �. 7—On QENEnATOR 8 REGMMTM A <br /> 2A.DESCRIPTION Of WASTE 25. CONTAINER TYPE <br /> REGULATED MEDICAL WAS n os.Afi.220.. KO.OF 20. VOLUME <br /> CONTAINERg <br /> UN 3291.PGif EiOT- IM, 9965 - BioSystems Sharps Treats Cart (59 cu ft) <br /> REGULATED MEDFM WASTE,n.o.s.,6.2, C <br /> UN 3291 poll KAB1 - BioSvxtema Trantsports Box (4.3 ou to <br /> CCREGULATED MEDICAL WASTE,n.o.s..6,2, Ct <br /> RUN 3291,PG 11 <br /> Q REGULATED MEDICAL WASTE,n.a.6.,8.2, <br /> CC UN 3291.PG 11 <br /> W REGULATED MEDICAL WASTE,n.o.s.A.2, <br /> W UN 3291,FG 11 <br /> Vr REGULATED MEDICAL WASTE, <br /> UN 3291,PG it <br /> REGULATED MEDICAL—WASTE,,,..,j,.2. CL <br /> UN 3291,PG It <br /> REGULATED MEDICAL WASTE.n.os.,6.2, <br /> UN 3291,PG 11 <br /> 3.00AWetar's Certification:01 hereby declare that Ute contents of this consignment are fu&y and accuratsry TOTALS ► <br /> described above by the proper shipping name.and are classified.packaged marked and labelledlptsrarded,and cu <br /> are In aft respells In proper tlon for transpon according o appiicabie International and national govemm al rogutationa.. <br /> rIII Pdntedrt'ped Name SI nature OsieJ-Sr(o <br /> 4.TRANSPORTER 1 ADDRESS: Phone 'f- <br /> 11875 Whine Roe;: Fid A&el IL — 5508 <br /> o <br /> a&JIL". <br /> H 3T�'iAICYCj.rE` This 1d 7 Tht:outJtl 9hipmQnt <br /> L TRANSPORTM— F [y Warsd)bal waste as described <br /> Pdnt/Type Name spnature Date <br /> S.INTERMEDIATE?HAMMER 2/TRANSPORTER 2 ADORES& Phare N: <br /> APPttcabla Perms Numbers: <br /> if <br /> MTERIJIEDIATE HANDLER/TRANSPORTER CERTIFICATION, Receipt of medtcal waste as described above. <br /> 11 <br /> Pdnvpme Nance- - Signature. Date <br /> i G.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Pham A <br /> AppncaW Permit Numbers: <br /> INTERNIE ATE HANDLER/TRANSPORTER CERTIFICATION:Raoetpl of medical waste as desertaaa above. <br /> i� <br /> # Pdnv ypo Nance Signature Dote <br /> 7.DISCREPANCY INDICATION <br /> Trans I 'ed_L CC Mainers, 60' cu R to: North Salt lake, UT <br /> O 8A.13eslgneted Faan4Y $9.Attenaft F801ty: IiC.A►temals Feclllty: f BD.Alumnte Ftxiltty <br /> STERiCYCLE.INC. 'TEfiICYCk.E.INC, STERICYGf Er�/� <br /> 1349 DDofittle Drive.Suite C 4135 W.Swift Avenue INC.INGST 2 Starr Ir INC. <br /> B911IDfd1 11s?0 We';t i@i2 Stair Dr <br /> San I.eandro.CA 94577 Fresno.CA 93723 North Salt Lake,UT 84054 Yuba City,CA 9599i <br /> u f 5191582- 1781 069)275-0994 ($01)938. 1555 f5301 790-t}170 <br /> ff TS31,T$IOraT25 T510ST 22 Claws Indrerraatioon [Paafs_' I!!Gi P-6,P-115 <br /> TREATMENT FACILITY:I certify that I have been authorized by the ap U to accep�un reate medical wastes rid that I have <br /> received the above i e tae In atamrdance with the roquir o n, <br /> J <br /> Prinvtype Name R lff�R Signature '' <br /> Oats <br /> 000894crrtG <br />