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rtx nate/Time JUN-17-2011 (FRI) 12:05 P. 014 <br /> 05/17/2011 FRI 12: 18 FAX 2014/028 <br /> 0'6'0 &terlcyde' Rol S QP YJTQ*CY CONTACT6bfy %1-"ft"Q8W— MPRC � tgar��rtal ont•toas s� <br /> 1.Generator's Name,Address and Telephone Number r ■r eee a■ r■p� <br /> A����• uSY�� aiV�4J it � ■■ �Q1�1 � � �� � � �� Y � <br /> BIO/LODI MEMORIAL, HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI . CA 95240 <br /> (209) 334-3411 4/9/2010 <br /> CwrTOMER Numom 60890 7-002 109NIR roe's R9GISTrt►„tto1641 <br /> 2A.DESCRIPTION OF WAST£ 211 CONTAINER TYPE 2C No.OF 20. VOLUME <br /> REGUL TE0 MEDICAb1Ny,UN 3291.PG 11 ;p 2' 65 - BiaSysitms 5tiarpc Trans Cart (59 cu ft) GSA 11A C. <br /> eRs <br /> UK3291 <br /> REGULATED MEDICAL VIIA$TE,nQs„62, x Biosystems Transport Box (4.3 cu it) <br /> UN 3241.PG tl <br /> REGULATED MEDICAL WASTE,a.0.s.,6.2. <br /> Crr <br /> UN 3291,PG ll <br /> C <br /> REGULATED MEDICAL WASTE,9.D.5422, <br /> iY UN 3291.Pe Il <br /> UJ REGULATED MEDICAL WASTE,n.0.84,2, Cu <br /> W UN 3241.PB 11 <br /> GJr REGULATED MEDICAL WASTE,n.os.,6.2. Ou <br /> UN 3291,P811 <br /> REGULATED MEDICAL WASTE.n.o.s..6.2, <br /> UN 3291,PS ll <br /> REGULATED MEDICAL WASTE.n.0.s_,6.2. <br /> UN 3281.PG II <br /> F 37L <br /> Cu <br /> �ssY (v <br /> 3.Generatatn Certificallon:'I hereby declare that the contents of this conslgnmertt are fully and aocuratefy TOTALS ► 2 , j Z <br /> described above by the proper ehOptng narne.and are clasatW,packaged,marked and labeledlplacarded,and ct► <br /> are in All respects In proper conSHon for transport according to applicable international and nationalnmenud r <br /> f gover g�ydatiortg• <br /> !I <br /> I � 1PrInteiVT Name Signature pate -9'lO <br /> >z 4.TRANSPORTER t ADDRESS: <br /> i°r1h.) 98b - 5506 <br /> 11075 White Rock Rd App! able Permit Numbers: <br /> g ti'I'ERxCYCLE 0 Thia is a Through Shipmcnt <br /> zTRANSPORT IMERFIFRMMIa MrM waste as described above. q <br /> Print/bype Hama SignatuT9 Date / -/O <br /> 6.INTERMEDIATE:HANDLES 2/TRANSPORTER 2 ADDRESS: Phone 9: <br /> i <br /> AWkable Permit Numbers, <br /> I <br /> = IN'T'ERMEDIATE HANDLER/TRANSPOMEIR CERTIFICATION:Receipt of medicab waste as described aioye. <br /> Print/Tw*Name Signature Date <br /> 6,1WERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Rhona A: <br /> P401CWO Permit Numbers: <br /> INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION:Receipt of medical waste as desulbed above. <br /> PrintrFype Name Signature Date <br /> 7.OISC19EPANCY INDICATION <br /> Transfe ed containers. � '19�cu it to : North Salt lake, LIT <br /> ❑8A.0eslraWFeci t : B.Alternate 11C.AhameFaciyGD,AllmaUFac111ry:at - : <br /> glaoh <br /> STERICYGLI=.LNG. GTMOYCLEANC. STERICYCLE,INC. STERICYCLE,INC. <br /> C 1345 Doatit&Drive.Suite C 4135 W.Swift Avenue 90 North,1100 West 1812'Starr Or <br /> - Sall Leandro.CA 94577 Fresno.CA 93722 North Salt Lake UT 84054If <br /> ba Gny CA 95991 <br /> (510!362- 1781 (5591275-0994 (0011 936 Yu <br /> - 1555 Yubaf5301 55-4585 <br /> TS3e m/r0eTY5 TSIOST 22 Gassil(Adneratio P0-8,P-1I5 <br /> 1 TREATMENT FACILITY-j,,ceqL%IhaI t have been authorized by the ap 7 e accept untreated medical wastes nd that I have <br /> received the atatry ted tes In�ar=rdance with the require III n. <br /> Print/rype Name �”ti�� Signature - ? <br /> • Date / <br />