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t(x Date/Time MAY-25-2011 (WED) 15: 35 P. 038 <br /> 05/25/2011 WED 15: 55 FAX 0036/049 <br /> 47* S1r:rIlj/!19' pC %SE4°F P,"GWYCONTACTRp4V..C_%aj"T4= "' MDRCtIMtAN:FEST00t'to-w-STD <br /> 1.Generators Name,Address and Telephone Number <br /> 7►�rrm�r• r_a.. a Mne cess ��� ��IOII <br /> BIOILODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95290 ' <br /> (203) 354-3411 7/9/2010 <br /> CtrsroMEr4 NUMBER 60 g 9 0*7'r—0 0 2 - GWEPATCR'9 REOLs pjffM II <br /> 2A.DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C. N0,OF 21). VOLUME <br /> UN36.2,pall ��M�'�t@ Mk65 - BiaSpsteum Sharps ns TraCart (59 au ft) CONTAINERS <br /> 6 IPG(iRegtrTatrdMedltalWaste,nC1 <br /> os.. � _ Biosystetnt Transport Box (4.3 au ft) <br /> X UN3291PGIRegulated Medrcat Waste.n.a.&. Ci <br /> UN3291,Regulated Medial Waste.ao.a, .0 <br /> 6.2 PGII <br /> 11 UN3291 Regulated Media!Waste.n.o.B., <br /> 62,Pall <br /> UN3291 Regulated Medkal Waste nAs., CL <br /> 6.2,Pali <br /> 2ll ReguWed Medltai Waste,n.0 M. L <br /> tjzill <br /> 6.23PGII Regulated Medical Waste n.o.s„ <br /> A= Ct <br /> 3.Generator*Certlncation: i hereby dectara fret the ccntonts of this aonstgninenl Bre tuSy acrd accuratety TOTALS ► rd <br /> � ;1,1. <br /> ddescribed all ra trove by the proper shipping name,and ars aassiTled,packaged,marked end labetied/plaoarded,antlCt <br /> Nis Proper diort for nspoR according appNcable Intemall"WW national governmental regal ions." Q <br /> A3 d�T o PrintaName Signatme Date <br /> 4.TRANSPORTER t ADDRESS: Phone <br /> 16) gas - 5806 <br /> 3.1875 White Rock Rd � Applicable Permit NumbeW <br /> ZTER3.CYCLE Thin is a Through Shipment <br /> TRANSPORTMFOE#R ?R a��al waste as described abom <br /> Print/Type NameSignature Date <br /> S.INTERMEDIATE HANDIER 2/TRANSPORTER 2 AD11 DRESS: Date 1-0 <br /> p: <br /> v <br /> gg Applicable Permk Numbsm <br /> it INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION; Receipt of medical waste as descrdsed above. <br /> PdnMpe Name <br /> Signature Data <br /> Al S.INTERMEDIATE HANDLER 3/TRANSPORMA 3 ADDRESS: Phone N: <br /> ApplleaWe Permit Numbers: <br /> INTERMEDIATE HANDLER MANSPORTEA CERTIFICATION:Receipt of medical waste as described strove. <br /> PrIn Viype Narne <br /> Signature Data <br /> T.DISCREPANCY INDICATION (G�� <br /> Transferred�Containers, l cu#t to : North Salt lake,UT <br /> 6A.t)es(gnated fertlily; s6.Ahernete FectBty: BC.Altars Fae(Iltlr. <br /> STERICYCLE.INC. STERICYCLE.INC. STERICYCLE,INC. ST BICYCLE,INC. <br /> 1345 0004111e Drive.Sine C 4135 W. Swift Avenue 90 North 11100 WU e� 19112 Starr Dr <br /> Sart Leandro.C:A 84577 Fresno.CA-93722 Borth yah E akQ, Yuba City-CA 9'5991 <br /> (510,1592.1781 (5591 2 75-0994 (80 11 938- 1555 X30175 0585 <br /> Sw?. S;'JST25 TSr05T 22 CtassV lncicte n �t -p- <br /> TREATMENT <br /> P 115 <br /> TREATMENT FACIU7Y:I certify that I have been authorized by the appllcabie sta agen t pt unirt3ated dicot wastes and that 1 <br /> received the above indica in accordance with the requirement have <br /> • q .,Qt/, � in that_ _..�r ion. <br /> Prhrt/Typa Narne � fr Signature f ✓• 'G+% a <br /> Date <br /> na�nar u <br />