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.,. UGLUI I11ur oun-1l-LU11I11t11 12:U5 <br /> 06/17/2011 PRT 12: 16 FAX P. 009 <br /> • n+swu+a4'w;Fwres,Iok2009/028 <br /> Route #: - -- ...- 800-424-9300 MI►�1'[1041IA <br /> t.Generator's Name,Address and Telephone Number f <br /> A':'T!';: Gvle Moses <br /> SIO/LODI MEMORIAL, HOSPITAL <br /> "S SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> 209 334-3411 517/2010 <br /> t.US70MMER NUN" <br /> QENERATOM REarsrnAroN 0 <br /> 2A ©lrSCRIPTit7NOFWASTE 28. CQNTAIHER7Yla$ <br /> UN3291 Regulated MeftA Waste.n.os., 2C,N0.OF ZD42 CY <br /> . VOLUME <br /> 6.2. >RR6S - BLOS stems SbAZP9 TX&nS Cart (59 CSM ft) CONTAINERS <br /> UN3291.Regdgad Medical Waste,n.o.s.. Ci <br /> 6.2.P011 $g _ SioB Ytems Trapaport Sox (9.3 au ft) <br /> jSU23PGt1 Re9ulatee Medkal Wast,. Ct <br /> UN3291Regtdated Medttat Wast,,111.01S.,X 6.2.PGII <br /> u UN329t Regulated Medkxl W85td,nAs, G <br /> y 6.2.PGII <br /> 6ti�N3�i1 Reputaled Medical Waste.no.S.. G <br /> UAt3241.Regubted <br /> Med Waste,n.6.s.. G <br /> a.2 PGfI <br /> UN3291.Regulated Medica!Wash,R.o.s., G <br /> 6.2,PGII <br /> QQ�� r <br /> �•�il <br /> urix <br /> 3.Generators 'I hereby dedam thea!the wnleMs of this wnsiprunant are fully and acNratey KTOTALES11- <br /> Certillcadon, Q <br /> described above by the proper shipplre lame,and are classified.petckagad marked and fully a df accacaurately <br /> tJ <br /> are in all respects in Proper conddlon for transport according to*Wp -.able International and= 8d.and R <br /> f govern nisi ulatiorts.' <br /> ,Prfnted/TypeO Nema Si <br /> 4.TRANSPORTER i Atll]RESS: <br /> natVred�A� Date <br /> Ptrone aq; g� g <br /> Q 11875 White Rock Rd <br /> APPu�at�P9-1?4%bew 55 O'S <br /> sT£AZCYClot This is a 'Through Shipment <br /> TRANSPORT%%, R� waste as deserbea above <br /> PrInVType hlmt►e Signature r�-7.16 <br /> S.INTERMEDIATE HANDLER 2 f TRANSPORTER 2 ADDRESS: Data �✓ <br /> Phone x: <br /> APP*able Permit Numbers: <br /> INTERMEDIATE HANDIER/TRANSPORTER CF <br /> RTIFICAPON:Receipt of medical waste as described above. <br /> PrinMpe Name Signature Dale <br /> W 6.INTERMEDIATE HANOLER 3 f TRANSPpfiTER 3 ADDRESS: <br /> q Phone#; <br /> Applicable Permit Numbers: <br /> INTERME=DIATE HANDIER/TRANSPORTER CERTIFICATION: Receipt of med+Cat waste as desuibea above. <br /> PdnUType Nares <br /> Signature Data <br /> 7.DISCREPANCY INDICATION <br /> Trang d J containers,N VD Cu R to : North Salt take. LIT <br /> 6A 008(grlelpd Fads <br /> h: , .Altemase I aclllry tiC.Alternal.Facility.. AttM>ate Fadfity <br /> STERICYCLE.INC. STERICYCLE.tlI STERICYCLI`,INC. STERICYCLE,INC. <br /> 1345 D0010e Drive.Suite C 4135 W.Swift:Avenue 80 North 1100 WEst 18!2 Slam Dr � <br /> San E.eantlra.CA 99577 Fresno.CA 93722 North Salt Lake.UT 84054 Yuba C' ,CA 95991 <br /> (510)582-1781 (5591275-0994 <br /> TS31.TS(OST25 "MOST 22 6 (8Q1)B38. 1555 530175-0585 <br /> TREATMENT FAC I certify that I have been authorized by the applicable state a en <br /> rocelved the above in ' 776S in accordance with the requirement ou ' in th 9 p° oaf untreated medical wastes and that I have <br /> r <br /> Print/Type Name Signature _ Q <br /> Date <br /> d04�6>3 C� <br /> ............ <br />