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xx uate/'f ifae JUN-1 7-2011 (FR] ) 12: 05 P- 013 <br /> 06/17/2011 FRI 12. 17 FAX 14013/028 <br /> • ►.�.�;...�.. .� ant����: ��•.. ......,�tt�=�z-�I'=�°�tr'.�'_ MDRG{1D���=�....__.._. ...._... <br /> 1.Generator's Name,Address And Telephone Number I <br /> ATTN: Gvle Moses <br /> HIOILODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI . CA 95240 <br /> (209) 334-3411 4/16/2010 <br /> C MMert N UMIJEit 608901,17-002 <br /> GtxtEtulott8 REtasttutiprt t1` <br /> 2A.I)MRIP'nON 5i WASTE 20. CONTAINERTYPE 20. NCL OF 2D. VOLUME <br /> REGULATED UN 3291.PQ11E01CALWASTF s fit. IM65 - SiDSysta=S S COIYTAt RS <br /> tU�[��;i--88 ]335�� sharps Trnrss Cart (59 cu fit) <br /> REGULATED MEDICAL WASTE.rws,6.2, dig r C,, <br /> Uhf 3291,PG II 10t$S - Biosv!mems Transport Box (4.3 au ft) <br /> CC REGULATED MEDICAL WASTE,—AD-S,,0,2. Cu <br /> tQR t1N 3291.PC it <br /> Q REGULATED MEDICAL 1NASTE e.o.s,6.2, <br /> UN 3291 PG II <br /> W REGULATED MEOICAL WASTE,n.o.s.,6.2, Cu <br /> W UN 3241,PG II <br /> REGULATED MEDICAL WASTE, <br /> UN 3241,PG II <br /> REGULATED MEDICAL WASTE, o so.s.,6.2. Cu <br /> UN 3291,PG It <br /> REGULATED MEDICAL WASTE,n.o.L,6.2 Cu <br /> UN 3291,PG If <br /> Cu <br /> RXB IO <br /> 3.Generatoes Certification:"I ttereby declare toot the contents of ttus Consignment are tullyy and aocuralefy TCOTALS 10- Z Z <br /> descrlbed above by the proper slipping name.and ere classified,packaged.marked and Iabeifed/Aacard-I and Cu <br /> are in an respects at proper condition for transport accordi to applicable International and natlonal govemmanial regulatio <br /> fins." <br /> /,7 <br /> I I PrfntedJT d N Sze fore Date '!G/ <br /> 4.TRANSPORTER i ADDRESS Phone p� <br /> Appii (r Tule Pe)rmH Numbers:X546 <br /> r ].1875 WhitRock oak Rd � <br /> gST£RICYCT,i~ �h F This in a Through 5hipmanU <br /> a TRANSPORT >$F 80421 waste as dewrtbad abon. <br /> Prhmpe Name Signature - <br /> Date <br /> 5.INTERMEDIATE HANDLER 2/TRANSPO1Tr'ER2 AD RESS: V Ptmv a; <br /> Appffcable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medkmi waste as described above. <br /> PrinVType NameDale <br /> Signelure _ <br /> 6,INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS. Phone 9; <br /> Applicable Perrrdt Numbers: <br /> 00ERi11EDIATE HANDLER/TRANSPORTER CERTIFICATION.ROC64M of medical waste as described aWw. <br /> PrfnVType Name Signature _. gate <br /> 7.D1.SCREPAJCY ItaCATION <br /> Trartsf tTEdQ&containers, �_Du ft to: North(Salt take, UT <br /> • O8A DaslanatBd Fatf[Hy 88.Attemate FaeNtty BC.Ahamala Fasfaty / U 9D.Alternate FSCnfty: <br /> 51 STERICYCLE.INC. STERICYCLE.INC. STERICYCLE,INC. STI=RICYCtI ,INC. <br /> C 1345 Doolittle olive.Suite C 4135 W.Swift Avenue 90 Notch 1100 West 1012 Starr Dr <br /> San Leandro.CA 94577 Fresno.CA 93722 ftlatth Salt Lake,t!T B4t354 Yuba C'ft�r CA 95991 <br /> ' f5101502- 1781 1`5591275-13994 (8011 830- 1555 (5301755-0585 <br /> E tS31,MOMS ividisT 24 Ctass V itdnerudot't PenN*t#t3 P-4.P-S t5 <br /> pSFT i <br /> TREAThIEEHI FACILITY: I cortify that I have been authorized by the appI66 a c euntreated+nedicat wastes athat I haus <br /> received the above indicated sl accordance with the requirement o Inthat Ion, <br /> PrinVTWpe Name Signature Date <br /> 000867 <br /> t <br />