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6.0 Stericycle- IN CASE OF EMERGENCY CONTACT;CKEMTREQ:A00-4211z93UV-'--
<br /> Route #i 410 600-4.24—q100
<br /> MD A(30•/-7,
<br /> 9 L9
<br /> 7. GeAerator'sNam3,Ad $s and Telephone Number
<br /> ATTN" GPIrl- Mo?,e5
<br /> B10t:140DI MEMORIAL HO'S'PITAL
<br /> 9.7�-e4K)UTH FAI.PNONT . DRIVE
<br /> LODI . CA. 9524-6
<br /> (209) 334--, 411. 61'1B/2010
<br /> CUSTOMER NUVUE`i GENERATOWS RMSTRATION
<br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 20, NO,OF 20. VOLUME
<br /> UN3291 Regulated M CONTAINERS
<br /> 6.2,PGII 961VAM RR65 — Hia9yotemv SIL&zpv Tran-v Cart (59 ou ft)
<br /> UN3291 Regulated Medical Waste,n,o.S.,
<br /> 6.2.Pell KRU - Vioflywtemz Tranvporr. Bog (4-2 V13 fi')
<br /> a,Waste.A-0-0.,
<br /> U143291 Regulated Mudi7 Cu
<br /> 6.21 FGII
<br /> UN32911 Cu
<br /> 6.2;PGIi Regulated Medical Wave,fl.oji"
<br /> U.N3291 Regulated Medical Waste,ri.o.s.. Cu
<br /> 6.2,PGII
<br /> Cu
<br /> UN3201 Regulaled Medical Wao,F1.0's".
<br /> 6.2,KII
<br /> UN3291,Regulated Medical Waste,FI.O.S., Cu
<br /> 6.2,PGII
<br /> UN3291 Regulated Medical Waste,n.0,S.,
<br /> 6.2.PGII
<br /> Cu
<br /> 3.Generator's Certification;'I hem6y.dociare that the contents of this consignment are fully and accurately TOTALS IN- --,;ZA- -2,. Cu
<br /> described above by the proper rhtpping name,and are classined,packaged,marked and labelled/placarded,and
<br /> are In all respects in proper condition for transport according to applicable Inlornalional and national governme tat regulations,"
<br /> XPrinted ped Name IC; q �xee- Signature Date
<br /> 4.TRANSPORTER 1 ADDRESS; Phone A
<br /> Appilcable Permit Numbers;
<br /> 1167a Whi-,v, Rock Rd q1hj-,t Thr*ugh ��hipmftllt
<br /> ISTVIRIC%rc LV
<br /> TRANSPORTE1"E i VF10AT40N cUpt AV4da(waste as described above,
<br /> Print(Type Name Signal. Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2AODReSS- Phone N;
<br /> V. Applioablo Pormll Numbers
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical wasto as clescrlbed Abow.
<br /> Printrilypo Name Signature
<br /> 6,INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: AMUr SI-XILT,hj!L,(Ipj
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, SERVICE MTE• 5118110 7f31:11 M
<br /> DRIVER 10:
<br /> Print/Type Name Signature
<br /> 7.DISCREPANCY INDICATION silipplic 0MWJ9"#:
<br /> .N-D,
<br /> w ft to � North Salt lake, U TOTAL M[E-u 26
<br /> rrans rred Q5 contatners, TOTAL t%
<br /> & 266,200 Cu n
<br /> 8A.Designated Facility: E&'�13�Alternate Foplilty; BC, Favi Ity,
<br /> TA (6 : lt'A(Xyk 1(11135 MAW Kilos
<br /> /�' /10 1 (' ')W/') Ah"O� KIh
<br /> ?"IA�RF-YQ .114C. KN I .'Yci—MIC. gggYqINC 004M N I RXF
<br /> 34, ooliule Drive.Suite C Sw Avenue orul I Hoek 111*10,Re WAOM no, V.J10414A RAI
<br /> Safi Leandro.CA 04577' Frerno.CA 93722 Nonki Salt Uke,UT 64054 f(ft
<br /> 0M.RSI
<br /> RVI MA00011,
<br /> (5 10)662- f 78`1 (550)215-0994 (m)9367 1666 111"W�l RK01 offim rfxo I 'k:Af'10!lop
<br /> I vl� .
<br /> Tszt.Tsfos'TK TS�WF-��VNE ORTIZ
<br /> AUTOCLAVEDANNE -ORTIZ: 10011'(k' fig; jl"qj
<br /> TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreatO ODA=kxo I, (10AMi RX13 fdVVRQ�INS
<br /> received the above indicated wastes In accordance with the requirement outlined in-thal authorization.
<br /> PrIaMpe Name nature SliHlfNiYtCad lypelCITY
<br /> W)fl"Isy'-Itus qu Irma .i 17A 2al
<br /> ")SY x, 1.78 Inv[
<br /> PMrW98'jU
<br />
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