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,run 1 /`Lull (Pttl) tL:U� <br /> 06/17/2011FRI 12' 17 FAX P. 011 <br /> 16 Stericycie• IN CASEF kb,t� u 0011/0 2 8 <br /> ' <br /> ft -" xa��gd; Route �: Y1� t�vc t GaNTACTR6 SV k�at s�nn nvevurerear <br /> GU MDRC-10F rP <br /> I <br /> . or's Name,Address and telephone Number <br /> 1 11 il'' , .11-1,q��! <br /> ODI MEMORIAL HOSPITALOf 111 11 1111 <br /> OUTH FAI RMONT DRIVE <br /> LODI. CA 95240 <br /> (209) 339 -3411 4130/2010 <br /> Cusrnrrea NuMe>:n <br /> 2A. Gea <br /> DESCRtPTiON OF WASTE 2B. r nArop g iiEorCnu3rore s< <br /> REGLILATEDMEDICALWASTE. COPrTA1N@fiTYPE 2C.No.OF <br /> UN 3291,PG 11 00T-3P tom' KR65 - Exo3psfrcros Sharps Tratas cart (59 w it) VOLUME <br /> C0117A1FEEFtB <br /> REGULATED MEDICAL WASTE,nA.s.,Sz, <br /> UN 3291 PG li KRB$ - Bio3yst�a Tranovort Box (4.3 Cu ft) Cl <br /> M REGULATED MEDICAL WASTE.ti0.s.,6.2, <br /> iii--- UN 3291,PG!! CU <br /> Q REGULATED ISI CA <br /> WASTte,n 0s,6-2. <br /> Q UN 3291,PG k Cu <br /> RM tATED MEDICAL WASTE,'L04 <br /> 0 s 6.2. <br /> lZ UN 3291,PG 11 <br /> F(FU_ATEp MEDICAL WASTE.n.o.s.A.2. <br /> LIN 3291.PG II Cu <br /> REG ULATED MEDICAL WASTE,n.n.s.,6.2, Cu <br /> UN 3291,PG 1! <br /> REGULATED MEDICAL,WASTE,a.0,S„6z, <br /> UN 3291,PG 11 <br /> fig <br /> 3.Generatwe Ceraf olon:•1 he y C <br /> rp, dectare that the contents of this consignment are fully and accurately TOTAL$ ► <br /> P14, <br /> In all <br /> above by Lha proper shtpping name.and are classliied.Packaged,marked and labelied/platsrded,and � Cu <br /> Are In att respects In Proper ftion for transport according to aPOkable intan+allonat and national nmental <br /> 9� regutatfons' <br /> PdntedlT ed Na <br /> t�SPORTER 1 ADDRESS: Dale <br /> 1B) 9B5 '^ 55116 11875 White Rock Rd APpf a PemrB Numbers: <br /> B`i`£RICYCLE j( Thin is 2 1%rough Shipment <br /> L TRANSPOMMItre . ..coft C9 ' waste as daccrlbed terve, <br /> Prtnf/fype Name Signature Q <br /> 6.INTERMEDIATE WANGLER 21 TRANSPORTER 2 DRESS: Date f <br /> fPhvrre a: <br /> APPS®bfe Permit Numbers: <br /> INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION,.Receipt 01 medical waste as desrJtbed above. <br /> PftVThw Name Signature <br /> Dale <br /> 6.INTERMEDIATE MANDLER 3l TRANSPORTER 3 ADDRESS, <br /> ? pftwo 0. <br /> Applicable Permit Numbers: i <br /> INTERMEDIATE HANDLER/TRANSPORTER CEMIFICAT10N:RaWpi of medoat waste as desuibed above. <br /> a: <br /> Pvint/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION nn jj � <br /> Transfe d d containers,/93 au It to : North Salt lake. UT <br /> �]BA tlesignafed FadFlty: Anemefe Fat pity: aC.Attemep FaeEt <br /> hY” �l!///u SD.Anernate Feelgty: <br /> $ ST>~RIGYCLE.INC, STERICYCLE.INC. STERECYCLE,INC. <br /> 1345 Doolittle Drive,Suite C 4135 W.Swift Avenue9Q North 11L7A West STERICYCLr=,INC. <br /> - San LeandrD.CA 94577 Fresno.CA 93722 North Ser /512 Starr dT <br /> (51f115B2- 1781 h Lake,UT 84Q54 Yuba Cly,CA 95981 <br /> �55��Z75-13894 (531755•Q565 <br /> TS34.TSK)ST25 TWST 22 [Bl?1193P- 1553 <br /> STREATMENT FACILITY:I CBrtily that I have been authorized by the a Cable stagy Vit <br /> r0ceived the above Indicated eS' ccOrdance with(he requirement o a urtlreaied medics!waste and that 1 have <br /> Print/Type Name nature Z. U <br /> ` Date <br /> n 1a 1'i 1 f; q <br />