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nx uaLt:/ r IMM: IRA I-L7-Gull twcvI 17: 31 N. UJ9 <br /> 05/25/2011 WED 15: 55 PAX 2039/049 <br /> •�M� stericycle' IN CASE OF EMERGENCY CONTACT;CHEMTREG 1n� MNDMO MANIFEST 00f-ts}-wwro <br /> Route #: 413 3 800-424-9300 MDRC009B4E <br /> 1.Generator's Name Address and Telephone Number <br /> ATTN: Gevie Moses ij ar <br /> BIO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95290 <br /> (209) 334-3411 7/2/2010 <br /> CuMMEA NUMBER GVEaA70"Rr: TMATION, 7-002 <br /> • <br /> 2A.DESCRWnON OFWASTE 28. CONTAINER TYPE 2C. NM OF 20. VQLtrrrtE <br /> UN,,PPGlERegulatedM0}tya�te„ ., KR65 - Biasystcus Sharps Tram: Cart (59 au ft) CWfTAIreERs <br /> -5P 1 CE <br /> UM3291,Regulated MOW Wasta,n.o.s., MBX - Birs9yetems Transport $ox (4.3 cu it) <br /> 62.PGII <br /> G <br /> C UN3291 Regulated Medkxl Wase.nAs., <br /> 6.2,PGI <br /> Cs, <br /> UN3291 ReQrdated MediCO Waste.nos.. <br /> 6.2.P0I1 C► <br /> U UM3291.Regulated NtWicat Waste,nos., <br /> dS <br /> 62.PGII C <br /> 3 UN SII Regulated RM waste.nos„ <br /> UN3291 Regulated IMiadicai Waste.MOS., C� <br /> 6.2.PGII <br /> UNU91I Regulated Medical Mste,nos., <br /> 91.7 <br /> 3.Generstar's Cartlficatlon:'t hereby declare lhet the contents of this consignment are linty and awl at* TOTALS► <br /> tl&Wribed above by ft proper shipping name,and are classified,packaged,marked and Ia IstIlMacarded,and <br /> are In all respects In proper condition for transport according I appficeWe Intemallonal and national Bove tal ul s" <br /> Xy <br /> I Pdnteowwd NameI"Ay Slgnalure to—7-L �Ll <br /> 4.TRANSPOATE11 i ADDRESS: Pho <br /> rlt15) 985 - 5506 <br /> #.1875 White Rock Rd a Pa+me Numeers: <br /> a 'Yip i� .� Through Shipmentnx <br /> N �TERICYCIe£ <br /> j TAANSPORTE"fPREPITIFDATbR.Oftript o°AU&waste as described above.Cr <br /> .. <br /> ~ PdnVTypa Name ) <br /> SiQnpture Data -7•C'-f <br /> S.tMTERMEDINM HANDLER 21TRANSPORTER 2 ADDRESS: Phone N.- <br /> :15 15 <br /> Apprrcable Permh Numbers: <br /> INTERMEDIATE HANDLER f TRANSPORTER CERTIFICATION:Raoeipt a medicai waste as descttbed above. <br /> PrinVrypa Name Signature Date <br /> 6.114TE EDIATE HANDLER 3/TRANSPORTER 3 AWRESS: Prone M: <br /> Applicable Permit Numbers; <br /> x INTERMEDIATE'HANDLEIt/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> E PrinVype Name Signatum Date <br /> 7.DISCREPANCY WDICATION <br /> Transferred C� o cantainers, 7 7c�-Cu R to • csI 1 2 <br /> & OMT17 <br /> DATE <br /> [j8A.0"19MW Faegtty: %61ttemet rftwdoq: 60,Altarru Fac ty�:CYC INC. I C INC. �rth t YYe � 6 Z 103Ca! e�irtve.Shite C ��tAvenue a 1 tart r <br /> San Lean ro. A 94577 Fre.rio. -A 93722 North Salt Lake.Lit $4054 Yuba Cky.CA 95981 <br /> (51©)582- 1781 (5591 275-0994 (501)930- 155 (530)755-0585 <br /> TS(OST 22 aiss+11t►dr+t?t�P� ,P-t 15 <br /> TREATMENT FACILITY:I certify that I have been authorized by the applicable stateagency to ept untreated medical wastes and that I have <br /> received the above Indica a n accordance with the requirement Dull' ata i Ilan_ <br /> //-,pbo <br /> PAnt/rype Narna ��� Si�rature + Date <br /> �a0933 <br />