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trx Date/'rime JUN--17-2011 (FRI ) 12: 05 p 012 <br /> 06/17/2011 FRI 12: 17 FAx idi012/OZ8 <br /> �"'� c <br /> 'r�ft ft.0%°r•Ad�"p1",; me.AaC tlr rra"u rm;T%;urr rAt;r: CM ur, I mLt,1"OWT �. u.iurwan..mnev,rgb,W8-1VyV'CC1W <br /> �•' h .A <br /> Route #: 413 3 $00-929-9300 <br /> MUCOOSYL9 <br /> 1.Generator's Name,Address and Telephone Number <br /> DIO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> 209 354-3411 4,x23/2010 <br /> Custt>Wa NWlaen QErreruiTows REau;TnAnort C <br /> 2A.OESCRIPTiONOFWA5TE 2a4 CONTAINER TYPE <br /> REGULATED MEIN ������ ZC.NO.OF 2tf. VOLUME <br /> UH 3281,PG It � "�'�"355b �t l65 - SiOSpstems Shas:ps Trans Cart S59 cu ft) CO <br /> NTAINERS <br /> REGULATED MEDICAL WASTE,n.os..6 2, r C <br /> UN 3281 FG it IME w B.iosystr_ms Transport Bax (4.3 rru ft) <br /> tY REGULATED MEDICAL WASTE,n"c"s,6.2, C <br /> 0 UN 3291,PG if <br /> Q REGULATED MEDICALWASTE,n.o.s..62, C <br /> a UN 3281,PG 11 <br /> LIJ REGULATED MEDICAL WASTE,n o.s.,6.2. C <br /> W UN 3291.pa II <br /> 0 REGULATED MEDICAL WASTE, C <br /> UN 3291.PG ti <br /> REGULATED MEDICAL WASTE, <br /> UN 3291,PG 11 <br /> REGULATED MEDICAL WASTE. <br /> UN 3281,PG N <br /> C <br /> RXBI <br /> 3.Generator's CeRlflratlon;h hereby declare thst the contents of this consignment are linty and accun tety TOTALS M Z <br /> described above IN the proper shipping name,and are dassided,padtaged,marked and iabaltattrptacarded,and <br /> Fare in all respects in proper rtion for transport atk:o to applicable International and national gover tat IID!!S <br /> 15� <br /> f �Prtn Name Slgneture Date <br /> 4.TRANSPORTER i ADDRt;38: Phone#-. <br /> AppGC881tmN1Vliiibgrg:55 0 fi <br /> 21875 White Roc--k Rd <br /> 51PERICYCLE E! Thim is a Through Shipment <br /> TRANSPORTER M wade as described shore. <br /> ArtnVtypa Name Signature Data ' <br /> 6.INTERMEDIATE HANDLER 2/TRANS RTER 2 ADDR Phone a: . <br /> 3 Applicable Permit Numbers: <br /> 3 <br /> INTERMEDIATE HANDLER ITRANSPOATER CERTIFICATION:Receipt at medical Warta as described above. <br /> Printrryps Name Signature Data <br /> 3 <br /> G.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Ptwa a: <br /> 6j Applkabfe Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of modkal waste as described above. <br /> PIIrtVType Name Signature bate <br /> T.DISCREPANCY iNQfCATION <br /> r��tt TransferTedQ� containers, �•3oZ cu ft to : Nortfl Salt take, UT <br /> S L! ad Fae or. ata.Alramats Facility: 8C.Alternate Fetalty: SO.Alt nWft FeclNty: <br /> STUNCYCtFE.INC, STERICYCLE.INC. STERiCYCLE INC. STERi <br /> CYGf. INC, <br /> 1345 Doolittle Drive.Strife C 4135 W.S`wiftAvenLle 813#forth 1100 West 1$12 Starr Or <br /> San Leandro.CA 94677 Fresno.CA 03722 North Salt lake,UT 84054 Yuba City.CA 95891 <br /> u [5101 562- 1781 [6561 276-0684 ) [530)755-0585 <br /> B � T'S3t.TSfOST2g 09P4 (80 1)63$-1555 <br /> TSIOS� 22 CtassiV tncinam"n L VP�t'�rn itx 91 PA P,11G ia <br /> TREATMENT FACUTY:I certify that I have been authorized by the ar Fah, �rrit,t 17w medical wa as and t at I have <br /> received the above indicated wastes In accordance with the requirement ogUine hat r 11on. <br /> PdnV7jrpo Nameit <br /> Signature Dara IO <br /> �`� <br /> .000533 <br />