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<br /> 1. Generator's Name,Address and Telephone Number N
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<br /> F I-O/LODI METAORT.AL HOSF I 'I'�L"
<br /> 975 SOUTH TYAMICINT DRIVE
<br /> -LOO-- - CA 9524--0
<br /> (209) 3:34•-•341 . .
<br /> f111.12t7J.Q
<br /> 2A.01 MERp!=$CR60 NUMBER (,1 GENERATOR'S REWSTRATION k
<br /> 2A, IPTION OF WASTE 2B. CONTAINERTYPE F 20. VOLUMI
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<br /> 2G. NO,UN3291 Reguialad M :yy8 t C- NO, el�s
<br /> 6.2,PGII U6VI , KRFiS - 3u5y t ins Sh z�rsx zmtts Cart (5S f-,u ft) /
<br /> UN3291 Regulated Medical Waste,n.o.s., ! Cu F
<br /> 6.2,PGII XRBX - binSVsi;an:s Trant:cport; box (4.3 au ft?
<br /> UN3291 Regulated Medical Eftte,
<br /> ., Cu F
<br /> 6.2,PG1I
<br /> UN3291 Regulated Medical ., Cu F
<br /> 62,PGt1
<br /> UNS291 Regulated Medical Waste,n.o.s., Cu F
<br /> 62,Poll
<br /> UN3291 Regulated Medical waste,n.os., C F �
<br /> 6.2,PGE!
<br /> UN3291 Regulated Medical Wasta,n.o.s., Cu F
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<br /> UN3291 Regulated Medical Waste,n,0.5•, Cu F
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<br /> 3.Generator's Certification;'t hereby declare that the contents of this consignment are fully and accurately TOTALS 0-
<br /> described above by tho proper shipping name,and are classified,packaged,marked and labelled/placarded, nd Cu f
<br /> are In all respects in proper tion for transport accord' to applicable international and national govem ntal ulationss- /�
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<br /> Printed &)
<br /> lT e, Nam a�1f"1 S nelu t 'cam "� Dale
<br /> C TRANSPORTER 1 ADDRESS: I Phone9.
<br /> I i%�mit umbers:
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<br /> 1 a.r?°3 �,�, � xte. �c0�"r eta � � Applicd ,
<br /> S'PFI�TCYt"uE: }�' Tlzi.t it, a 'T'hrougfi Shirmiont
<br /> rRANSPORTM,QAIK FUCKM, 141ft% f waste as described above.
<br /> ;IdnVlype Name Signature Dale
<br /> S.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone p:
<br /> Applicable Permit Numbers:
<br /> NTERIVIEDIATE HANDLER/TRANSPORTER CERTIFICATION: RecoOt of medical waste as described above.
<br /> lrinl/lype Name Signature Date
<br /> i.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: I Phone 4:
<br /> Appllcabto Permit Numbers:
<br /> NTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> 'rintflype Name Signature SERVICE RET"IN
<br /> DISCREPANCY INDICATION AMOUNT I: 6099077002
<br /> {% 81011-edf Ncaorial Ilospila!
<br /> Trans fe ed Containers,�a w Out ft to : North Walt lake, UT Sf:RUICE DATE; 6117110 7:16:I?AN
<br /> BA,Designated Facility: tf
<br /> 88,Allernalo F 0111 : 00.Attomato Faollity: OREVER 10: JON
<br /> (P j v Cv�� l/ S111110if t1 R1 i; i fiCbD47CT
<br /> a'T'I;RICYCI_E* INC. ST>~RICY IF,INC. STERICYCLE.ING.
<br /> 1346 Doolltfle Drive.Suite C 4136,W.Svi ftAvenue � 90 North 15430 West TUTAL MJECTEO: 21
<br /> San Leandro.CA 94577 Fresno,CA 93722 North Sit Lake,OT" 84054 TOTAL VOLUff: 200,660 CU I'I
<br /> (510)662- 1781 (569127 [8011936- 1 aa�a
<br /> ,. L NE oRriz rluhis1111 KRGS ooA04lfJ KR65 tXrrlclt 9 ra�Tli
<br /> T535. I SIC)a C2 T S!4`3 t UTaCtAVED 1 r ¢ 141nrn1PN RX01 00ADOPT)RXfil uOvApp 1(x11=
<br /> tr `' S rrrlArHd�U wil 0OAOOPR RKRI crlAlne llxPr
<br /> 'RE"ATIVIENT FACILITY; I certify that I have been authorized by the applicable state agency to accept untroatar 1k4V10P1 IIKRI 00A00P0 R::8I its Nft s;Kitt
<br /> neived the above Indicated wastes in accordance with the requirement outlined in that authorization. rlr'relC'If RXIII 00400PX RXOI iowih'
<br /> +il;<.i,;l','[;'Sit' 0GAa100 RKBI i.•.'arrUt ::1'Is,
<br /> rinVType Name R s. rs, rat•1 R1Ff� MAW 10111
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