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nx uaTe/rime JUN-I7-ZU111FRIJ 12,05 P. 017 <br /> 05/17/2011 FRI 12: 19 FAX 2017/028 <br /> i OF Sterlcycle' IN GA5 F G CYCONTACT• M^�� rBHpARp MANrfiESrp01•IM-STd <br /> Reuse F#° ' e ` ' '8' °°'t-" n t)_s�C�3 <br /> 1.Generator's Name,Addresfs and Telephone Number ! <br /> A:"TIK. Gvle ;dose., ! IIII 11T,®R ffiff , 11 ,! <br /> ( • HIO/LORI MEMORIAL, HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA_ 95240 <br /> (209) 354-3411 3/19/2010 <br /> CUSTOMER NUMBER' GEr MAFOR-s REe4TRk"N 1 <br /> 2A.DESCR1PT1ON OF WASTE 213. CONTAINgnTYPE 2C.NO.OF 21). VOLUME <br /> REGULATEDMEot HrAS a <br /> UN 3291.PG ff �O*S�'n16�' Rt65 - Sio5gstcass Sharps Tracts Cart (59 cu fit) CONTAINERS � <br /> AEGULATED MEDICAL WASTE.RA.s.,6.2, Ct <br /> ON 3291,PG 11 >{R$S - Bio3Ystems Transport Box (4.3 cu ft) <br /> g: REGULATED MEDICAL WASTE,nas.,6.2. Cr <br /> O UN 3291,PG If <br /> C REGULATED MEWCAL WASTE,mo.S7i.2. Ct <br /> CC UN 3291,PG II <br /> LLI W REGULATED MEDICAI.WASTE,R.a S A.2- Cf <br /> UN 3291,PG LI <br /> n REGULATED MEDIAL WASTE.nA,s.,62. <br /> UN 3291,PS 11 <br /> REGULATED MEDICAL WASTE•n.o.s.,62, <br /> UN 3291,PG It ' <br /> REGULATED MEDICAL WASTE,n.a.s..6.2. <br /> UN 3291,PG 11 <br /> AM <br /> 31 Q <br /> 3.Generstor's Certification.-"I hereby dedara that the oontarus of this consignment are fully and a=mtay TOTAL$� <br /> daes�bed above try ftpr"r shipping naive,and are c1milled,packaged,ma*ed and Iabello&placarded,andfe a <br /> especrs in Proper tion for transport according 10 OPpiicable international and national bntal Ia4 <br /> ionsX " <br /> IArirt Hama Signal Data 3' <br /> 4 TRANSPORTER i ADDRESS; Phone <br /> lbts 985 - 5506 <br /> 12875 Whits Rock RdkaWPermit Numbers: <br /> E IT S°1OUCYC3.E FK1 This is a Through ffhi.pment <br /> TRAM&POFtT1 =JMrq:7 <br /> a waste as decoted above. <br /> F Print/Type NameSignature —Oats- <br /> 5.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone M: <br /> App kabio Permit Numbers: <br /> i <br /> f <br /> INTERMEDIATE HANDLER(TRANSPORTER CEFMFICATION:Receipt of medical waste as described above. <br /> P,1nV7Vpe Name Signature Date <br /> i 6.INTERME=DIATE HANDLER 3/TRANSPOFITER 3 ADDRESS: Phwe 0. <br /> � <br /> AppAcaNe Permit MmyaoM: <br /> IEINTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:ReceiPt of medical waste as described above. <br /> ' Print/rypa Name Signature <br /> Date <br /> 7.DISCREPANCY INDICATION - <br /> TransferredQ3 containers. `/2(0 Cu ft to : North Salt lake, UT <br /> 3 Q ax Designated Facility: 08.Afternsto FecUlty: EZPC.Aitgmete Faclllry, � tib,AtramMe Facility: <br /> STERLCYCLE.INC. STERLCYCLc,INC. STERICYCL E,INC. v L <br /> STERICYCINC. <br /> L � <br /> 1345 DDoTlait?Drive.Suite G A 135 W,Swift Avenue 90 N Orth!IOU West 1812 Starr Dr IfV4 <br /> San Leandro.CA 94577 Fresno.CA 93722 With Salt Lake,UT 84954 Yuba Cfty.CA 95991 <br /> u (5#0)582-1781 1559)275-9094 �BOt 1938- 1555 # <br /> LE (5311179 -Oi70 <br /> 's TS31.TVOST25 TSI'OST 22 a t F•8,!'-115 <br /> TREATMENT FACILITY: rti at I have been authorized by the applicable to ag aCCOPI untreated medical w tes an that I have <br /> received the ab ted - +� <br /> s i��ante with the require t: to T Pion. <br /> fhirir/fyAe Name O/r/ 7V � e40e <br /> Signature Q�e <br /> eee26i <br />