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hx Date/Time JUN-17-2011 (FRI) 12: 05 P. 016 <br /> 06/17/2011 FRI 12: 18 FAX 2016/026 <br /> 9T8rCyC10'fr ,rrH l:Aiit VF tNr�Hrit1'ri:T t%4N - wq.TwOly <br /> Route 11: 413 9 600-424-9300 <br /> MDRGOOBTF.5 <br /> 1.Generator's Name,Address and Telephone Number ff � <br /> ATThX: GV1Z MCses <br /> SIO/LODI MEMORIAL HOSPITAL. <br /> 975 SOUTH FAIRMONT DRIVE <br /> UODI . CA 9529.0 <br /> 209 334-3411 3/26/2010 <br /> t usrouer;Ntr"T 7-007 GENEMtoR's RERLMxn*R <br /> 2A.DESCRIPTION OF WASTE 20. CONTAINER TYPE 2C. NO.OF 2D, voLt1ME <br /> REGULATUN 32111.PO it tCADIOAVS0 i.8M6.2, MR65 - $1o9 stems S GONTA1Nf2RS ' <br /> y heaps TreaS L;aart (33 C"ir ft) c„ <br /> REGULATED MEWiW WASTE,11.03J.2. <br /> UN329t,PG11 K1ZB$ - Bio8veteme Tranvnort Box (4.3 au ft) <br /> (r REGULATED MEDICAL WASTE,n.o.s.,6.2. Cu <br /> L� UN 3291,PG II <br /> Q REGULATED MEDICAL WASTE,11.0.5..6,2. Cu <br /> UN 3291,PG 11 <br /> LU REGULATED MEDICAL.WASTE.n.o.L,0.2, 1'te <br /> W UN 3291,Ps 11 <br /> REGULATED MEDICAL WASTE <br /> UN 3291,PG 11 <br /> REGULATED MEWCAL WASTE 11.0.5„6.2, Cu <br /> UN 3291,PG If <br /> REGULATED MEDICAL WASTE.n.0.5.,6.2, C <br /> UN 3291.PG if <br /> ©u <br /> RXBI <br /> 3.Genaralm'a Certification:•1 hereby aedwe that the Contents of this oonsigrmterd are fusty and accurately TOTALS P- 3 (, <br /> destxibed above by the proper shipping name.and are ciassffied.packaged.marked and fatialleftlacaroK and �+ <br /> am in at1 respecls in proper ndition for transport accords to eppricable International and national governmental regulations” <br /> IV P- <br /> Print ped Name Signature , Date 15 4'� <br /> 4.TRANSPORTER 1 ADDRESS: Phone <br /> tff'16) 955 - 5506 <br /> 11875 White Rock Rd APplici bte Permit Nwrogrs: <br /> E t3TEiZICYCi,£ This ie a Through Shipment <br /> i TRANSPORTQ1 waste as described ebm <br /> Prinsrtype^a"'e Signature Dare a LID <br /> 5.INTERMEDWTE HAWLER 21TAANspowER2ADDRESS. <br /> Appticabla Permit Numbera: <br /> INTERMEDIATE HANDLER f TRANSPORTER CERTIFICATION:Receipt of medical w85te Me described above. <br /> Print/Type Narm Signature <br /> Data <br /> G.INTERMEDIATE 14ANDL ER 3/TRANSPQRT'ER 9 ADDRESS: Phone#: <br /> Appticabie Pam*Numbers: <br /> gw INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medicai waste as described above. <br /> a PrinVType Name Signature Date <br /> T.DISCREPANCY INDICATION rU containers. car5 <br /> cu It to : North Salt lake, LIT <br /> 8A Oeslgnatea Fattliy: 88.Anamate Faeitlty f+c Attemats Feeiltty 8D.AWnM,Fbdllty: <br /> 5 G'YCE.F INC. gg f YG .INC, g�� `INC, u GY <br /> t �oolOja�lrh $7 uite C 4 Sw Ayi nue 90 too West �tarr r INC. <br /> • art can ro a��99 r7 Fresno.GA 837. NoM SA Lake,UT 84054 Yuba C''d�yy.CA 85881 <br /> (510)582- 17$1 (5693 275-0994 (60 1)036- 1555 (530)790*-0170 <br /> 3 TS31.ISIGST35 MOST 22 r Ss+/lttdrietl t m pem t#91 I?d F=S 15 <br /> c� <br /> pim <br /> UJkL C�RT`IZ <br /> TREATMENT FACILITY:I Certify that I have been authorized by the applicable state agency t pt untreated medical waste andt I have <br /> received the above Indicated wastes in accordance with the reclukement�n at lion. / <br /> PrinvVe Mame $"lure Date i <br /> 000371 Cy <br />