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xx vate/Time JUN-17-2011 (FRI ) 12:05 P. 015 <br /> 06/17/2011 FRI 12: 18 FAX 2015/028 <br /> i�• 5ienrycle• IN CASE OF EMERMCY CONTACT:CHEMTREC dg= kil2U,. bw%m su eennrrnsr wr•ru�ef y iu <br /> Route #: 413 -1 800-424-9300 )41)RCOQBU7,Q <br /> 1.Generator's Name]Address <br /> gatnd Telephone Number <br /> ATW:l�� V <br /> i vie Moses <br /> BIO/LODI MEMORIAL HOSPITAL, <br /> 975 SOUTH FAIRMONT DRIVS <br /> LODI . CA 95240 <br /> 209 '334-3411 4/2/2010 <br /> CUSMUER NUMBER 1508Wcow3I►ma's R:0tsrn�twrt I <br /> 2A.DESCRIPTION OF WASTE 29. COMAINER TYPE 2C.NO.OF ZD. VOLUME <br /> REGULATED MEQ W nAs.6 2 CONTAINERS I� <br /> UN 3291,PG ll D I ` RR65 - 0109ystems Sbasps Txaos Caxt (59 cu ft), Cc <br /> REGULATED MEDICAL WASTE,mo.S.,52, <br /> UN 3291.PG 91 i4t88 - VioSvstema Transport Box (9.3 est ft) <br /> LX REGULATED MEDICAL WASTE,a.o,9.,82. Q <br /> Q UN 3291,FG It <br /> IQ"- REGULATED MEDICAL WASTE,R.O.s.,6.2. Gr, <br /> LW$291 PG It <br /> LLI REGULATED MEOICAL WASTE,o.os.,8.2. <br /> Z LIN 3291,PG 11 <br /> REGULATED Mf0tCALW Ca <br /> UN 3291,PG.11 <br /> Ate'n 0,s.,ti 2, <br /> REOUiATED MEDICAL WASTE,n.oa.,62. + <br /> UN 3291,PG Ir <br /> REGULATED MEDICAL WAST£,nn,S,.8.2, Cu <br /> UN 3291,PD ii <br /> Cu <br /> R8$I <br /> 3.Generator's.Cer""llan:'I hereby dedare that the contents of this consignment are IuRy and accuratelyTOTALS 0 <br /> scrb <br /> deibed above by she proper shipping name,and are dasslfied,packaged,marled and iaballecilptacarded,and Cu <br /> are In all respects In properCo lora for transport according 10 apPIICable Imernb9onaf and national govern nlal r Ialfone <br /> rYljrped <br /> PrinteName <br /> Q 4.TRANSPORTER 1 ADDRESS: <br /> Ph°nZ�lb) 965 — 5506 <br /> 11B15 White Rock Rd AppricablePermitNumbera: <br /> [C 8'3'ERYCYCLE This is a Through Shipment <br /> q TRANSPORT011POWWRM4019 9k W68 waste as dowdbed a <br /> Pdnvfte Name „1 - Irt� She 'Z <br /> 1e <br /> I� <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Dalephone M: <br /> iADpkabte Permil Numbers: <br /> i INTERMEDIATE HANDLER ITRANSPORTER CERTIFICATION:apt al medical waste as described above. <br /> , s <br /> Print/rype Name Signature <br /> Ogle <br /> 6.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone M <br /> { Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpl 01 medical Waste as(18Scrlbed above. <br /> Prinlfrypa Name <br /> Signature D <br /> ate <br /> 7.DISCREPANCY INDICATION c <br /> Transfers d 9iS containers,ILI a'� cu ft to : North Salt take,UT <br /> eA De:tgnatedfacttity eB.AnemateFadn!!n Pq <br /> $0.AttemaleFecitity:/} t j /0 W.AttanutapW14: <br /> S ICY INC. RMCCA IINC. RI Y �NCf,`tde �CiNC. <br /> � dro.CAeGFr1�e 5s7L�nue Nor DSakit�ae84Q54 Yuba C1Iryry� ,95$81 <br /> f 51 Ry 582- 1781 (559)27 B-d994 $01)939- 1555 (530)756-05$5 <br /> 1531.TSfOST?5 T�+tJ 22 tEss'!Iminer6m Pero 81 <br /> ill-E N OR <br /> Y TREATMENT FACILITY. I cerlity that I have beers authorized by the applica ate Do at p1 untreated medical wast s an that I have <br /> received the above indica les in accordance wit3t the require 111 n, <br /> Print/Type Name $Oulu. Date 1 <br /> x00387 ��r <br />