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10 Stericycfe' IN CASE OF EMERGENCY CONTACT:CHEMTREC{ pa.G24.89AQ ST0.>�QARO MANt�EST e01•1e•06•S7o
<br /> ,� rwrKuyn.ae.Reaue nw: Route It. 413 -GoCJ---p 19Ga-929—fJ�gQ 7���C�1�g
<br /> 7nrir, s Name,Address and Telephone Number
<br /> BI MEMORIAL HOSPI'T'AL,LiTH F'AIkMON`T' DRI�JE
<br /> UA .-g.5�_74.a..._-. ----. ..
<br /> (209) 334--3427. 5/25/20 .0
<br /> GUSTOMUM NuMace
<br /> C}�tlElil4]9H'6 RrG13Ta0.71pt1 ti
<br /> 2A,DESCRIPTION OF WASTE 2tl, CONTAINER TYPE 20. NO,OF 2t), VOLUME
<br /> UN3291
<br /> 2.PGII Regulated Medical lNastc nn.s' M165 R Rios CONTAINERS
<br /> OVUM y1L-atas �herPz Trattv Cart (SS au fit} Cu
<br /> UN3291 Regulated Met'Icat Waste,n.os„
<br /> 6.2.PG II HRf38 -- B'io�vxzema Transport'✓ Box (4,3 au 1:t)
<br /> UN3291 Regulated Metlical Waste,n.os., Cu
<br /> 6.2,PGI
<br /> UN3291 Regulated Medical Waste,n.o.s., Cu
<br /> 6.2,PGII
<br /> UN3291 Regulated Medical Waste,n.o.s., Cu
<br /> 6.2,PGI
<br /> UN3291 Regulate([Medical Waste,—nos,, Cu
<br /> 6.2,PGII
<br /> UN3291 Regulated Medical Waste,—no's., Cu
<br /> 6.2,PGI)
<br /> UN3291 Regulated Medical Waste,n.v.s.,
<br /> 6,2,PGI
<br /> CtY
<br /> 3.Generator's Certification;"1 hereby dec(are that the contents of this consignment are Iul(y and accurately TOTALS ► ,
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelloWplacaud I and cu
<br /> are in all respects In proper condition for transport according to applleaWe international and national governmental(sDOatione
<br /> Printedfryped Nam "-i Signature r Date ` ,10
<br /> 4.TRANSPORTER t ADDRESS: Phone
<br /> 3.3.875 [White Bac=k Rd Applicable Permit Numbers:
<br /> EXI°T>1R� YCL£ TE�as i~r :a TiYtouki] Siyiprat:n ;
<br /> TRANSPORTOFIXORRUFOMONsaR shpt WWWRal waste as dasWbed above.
<br /> Printfrype Name Signature Data
<br /> 5•iNTERMEDIATE HANDLER 2/TRANS O TER 2 ADDRESS: Phone p:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION; Receipt of medical waste as described above.
<br /> Printfrype Name Signature I Lrarr iilst
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS:
<br /> SERVIl,1L
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Recelpt of medical waste as du In
<br /> above. AST li,
<br /> 6089071-002
<br /> Printfrype Name Signature 010/1-odi 6or€al Hospital
<br /> 7.DISCREPANCY INDICATION SERVICE DATE; 5125110 7:01:39 y1
<br /> �f DRI" ID: At
<br /> Tran5fsr ed Containers, L _ tri ft to : North Salt lake. U &HPAlhO f>OCIHEiTf i: M
<br /> =J= - f{tufCc���aK
<br /> 8A,Designated Facility: 8B.Alternate Fnotlltvr
<br /> 9 y� SC,Alternate Fa fli TOfAI. Ct�.I,F.CTf.TI; 1
<br /> S7� ICY II�lO. 7"'�iGYGIrE.INC. ERI Y .I{V f TOTAI. 1 OtfL; 4.320 CU!'i
<br /> 134 ooEltlie i�nve.Suite C 4a^51N.Swift-Avenue IVae l West o0A00Ve R1iD1
<br /> San Leandro.CA 94577 Fresno.Cly 93722 North S It lake,UT 84064
<br /> (510)562- 1781 (558)275-0994 Hg11 QN,- -1,6156
<br /> TR' 1 T ;r)ST7, T�10S V 77 � ��t �� FITt 3tnn(ARY(I l Type) Qtv Vol.
<br /> TREATMENT FACILITY; I oertify that I have been authorized by the applicable state agency to accept unlrea R>t001 �" "'`€ 0°x D€osy ' z�r
<br /> •eceived the above Indicated wastes in accordance with the requirement outlined-in 4hai authorization, ID IV-RV Ia)A+FpI Ir: PDRC0094,IK
<br /> Drinmpe Name Signaluro i01A1 Orl.m..'a''D ITERS: 4
<br /> ter _ TYK QTY
<br />
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