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nx Elate/Time JUN-I7-2011 (FRI) 12:05 <br /> 06/17/2011 FRI 12: 22 FAX P. 027 <br /> ��� -... .�.... - 027 0 2 <br /> �+.►bN..r.aa.oa.� RUute:-�: 4��-'!- 8�6��2+�` ����"����T ....._. ® / r 8 <br /> 11 Generator's Name,Address and Telephone NUmber <br /> LORI MQlilt <br /> �� <br /> ATT : way�� �� "mill1111 <br /> ''1 HOSPITAL IWEST FAC) <br /> 800 S LOWER SACRAMENTO RD <br /> LODI. CA 95240 <br /> (209 339-7668 4130/2010 <br /> Cil870M"NUMBER <br /> 2A.DESCRIPTION OF WASTE 26, QEN1�REL7grlraTtt]n <br /> REGULATED MEDICAL WASTE,n,o.s.,6.2, CONTAINER <br /> TYP TYPE 2C.NO.of 24. VOLUMF <br /> UN$291,PG 11 TBI4-(Bio) / TP14-(Fath) 44 Gal Tub (5.9 Cu ft) CONTAINEns <br /> REGULATED MEDICAL WASTE.n.o.ts.A.2, Cu <br /> UN 3291.Pg It T1321-(Bio) / T815-(Path) ! T1115-(Chemo) 2Q Gal Tub (2.7 <br /> W REGULATED'MEDICAL WAST£,n.o s..62, Cu <br /> p UN 3291.PG 11 T le TP49-(Path) / TY4 9-(Chemo) 37 Gal Tub (4.9 <br /> REGULATED MEDICAL WASTE,n.0.5-,&.2, <br /> UN 3291,PC,11 T525 - 26 Gal Tub (Sia) (3.5 Cu ft) Ou <br /> W REGULATED MI`IEDICAL WASTE,n.o,s.,6,2. <br /> z UN 3291,PG It TB57 - 90 Gal Tub (Sic) (12 cu ft) <br /> rU REGULATED M ICAL WASTE,ao s..6.2, (Sic) (6. Cu <br /> �—UAE_929i..PG,11 !P1364 48_Gal�'11J. 4 au #t) <br /> tf!! <br /> REGULATED MEDICAL WASTE,n.o s.,tU. Cu <br /> UN 3291,pQ EI - � <br /> REGULATED MEDICAL WASTE.n.o.s.,6.2, <br /> LIN 3291,PG 11 S764 - 64 Coal Tub (Bio) (9.67 au ft) <br /> Phamtaceutical Waste C„ <br /> ------------ <br /> L Generator's Certification:1 hereby declare Mat the contents of this consignment are luny and accurately TOTAL$ <br /> deaoribe by the proper shipping name,and are ciasslned,packaged,marked end labellodlplacarded and + 7 <br /> are In Cu <br /> peck in R► tion for Iransporl according to applicable International and national garem ental regular€arta.' <br /> Prix» 42 Sig nater <br /> .� d.TRANSPORTER t ADDRESS: Date � <br /> Phons N' <br /> 1.1875 White- Ftdd=1v"Rd �1�eimitgiCumbera:Sw aL <br /> _ -- ;3-TERICYCLE. _ ._ This in a Through Shipment <br /> TRANSPORTE&V <br /> PrMVType Name 1�bnsd 1 wai <br /> waste as <br /> iGT tL7 'In <br /> d atm. <br /> gatura <br /> 6.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Date i/ <br /> Phone e: <br /> ARFricabte Penn#1 Numbers: <br /> INTERAflEWATE HANDLER/TRANSPORTER CERTIFICATION:Recelpt of medical waste as described above. <br /> PrinVTM Name Signature <br /> Data <br /> 6.INTERMEDIATE HANDLER 31TRANSPOF rEn 3 ADDRESS: <br /> PtWne p. <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medic-al waste a$desefted abm-(L <br /> APp20trla Permit Numbers: <br /> x <br /> Printrryps Name Slgnalurg <br /> 7.DISCREPANCY INDICATION Dale <br /> Transferred--L containers, "t• CU It to : North Salt take, UT <br /> 8A Daignoted Fedltty 88.All.=FadW, <br /> ac.Allernata Fae <br /> Dll'• S,' /� e0.Alremata Facltiq': <br /> l STERICYCLE.INC. STERtCYCLE.INC. <br /> 1345 Doolittle Drive.Suite C 4135 W.SVWtAvenue S"IERICYCI.E INCItVG. STERICYCLE,INC. <br /> San Leandro.CA 94577 Fresno.CA 83722 9Q North 1100 est 1012 Starr Dr <br /> 1 (510)602- 1791 {559)273-0994 Nark Soft lake,UT 84051 Yuba C ,CA 95981 <br /> = z{ TS31.TS(OST23 TSf()ST 22 801 Z 836- 1555 (530)766-0566 <br /> TREATMENT FACILITY: cern that t have been authorized by the applicable state en <br /> P-tl5 <br /> received the aDov21Pd=0d0VMtes In accordance with the requirement out In!ham to accept untreated med''"I wastes and that I have <br /> oirzalion. <br /> PWYpaName Signature �.� Data MAY 0 5 Z010 <br /> (DOUG2. 5 <br />