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MEDICAL WASTE TRACKING FORM NUMBER <br /> +f i Stericycle, IN CAS F G CY CONTACT Mr q 1- �.q�q 9300 STANDARD MANIFEST OGI-10.06•STD <br /> �• .r,.�.�, hepl..e.e.d�Re► Route � � $�'4Z�9�qp MDRGO09FWV <br /> 1.Generator's Name, Address and Telephone Number VENINE11111111 <br /> lip E <br /> ATTN: Gavle Mases Ik till tf11[I{#il #1 <br /> BIO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> (209) 334-3411 7130/2010 <br /> CUSTOMER NUMBER 6089077-002 GENERATOIYs REGISTRATION tt <br /> 2A,DESCRIPTION OF WASTE f CONTAINERTYPE 2C. N0.OF 2D, VOLUME <br /> UN3291,Regulated Meqwwtq iQl6 ��$iosystems Sharps Tracts Cart (39 cu £t) CR ITERS <br /> UN3291,Regulated Medical Waste,n.o. L2 t� Cu FL <br /> 6.2.Poll g � aSvetems Transport Hex {4.3 Cu ft) �7 p. ��} ! <br /> fX UN3261,Regulated Medical Waste, .o. `Cu Ft <br /> 0 6.2.PGII fd Cu Ft. <br /> ~ UN3291,Regulated Medical Waste,n.o.s., i <br /> 6.2,PGII <br /> Cu FI. it <br /> EIJ UN3291Regulated Medica!Waste.n.os., I <br /> ! Z 6.2,PGliLLI <br /> j <br /> UN3291,ReguWed Medical Waste,n.e.s., Cu r1. <br /> 6.2,PGII Cu Ft, <br /> UN3291,Repuiated Medical Waste,n.a.s., <br /> 6.2,PGII Cu Fl. ! <br /> UN3291,Regulated Medical Waste,n,o.s., <br /> 6.2,PGII <br /> Cu Ft. <br /> MET <br /> I <br /> Cu Ft. <br /> 3.Generatora Certlflcatlorn•I hereby dedarethal the contents of this consignment are fully and accurately TOTALS ► �� u <br /> described above by the proper shipping name,and are classified.packaged,marked and labelled/placarded,and QFt. <br /> are in all respects In proper dition for transport acoor Ing to applicable International and national governme tai regulations" n <br /> Printedlrypetl Name Signature 7 Date 7 <br /> 4.TRANSPORTER 1 ADDRESS: Phone(SJ6) 985 — 5505 <br /> iL <br /> >:� 11875 White Rork Rd Applicable Permit Numbers; <br /> a O �TERICYCL£ x Thim i5 .2 Through Shipment <br /> itN A <br /> I a a TRANSPORTE F �€ fA7TC1�? r pt poi m7�1 al wasle as described above. <br /> ftni/Type Name Signature Data + 10/ 1� <br /> I p�C 'aY 5.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone A: <br /> F <br /> QW o 0e Applicable Permit Numbers: <br /> as� <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> PrinVrype Name Signature Date <br /> � 2 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone k: <br /> a¢ <br /> o�+ Applicable Permit Numbers: <br /> f g a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above, <br /> x <br /> — Print/Type Name Signature Data <br /> 7.DISCREPANCY WDICATION <br /> Transferred ?--- Jccntairters, to : North Salt lake, HJT <br /> Lh <br /> 8A.Designated Facility: 8&Altarnate Facility: ferrate Facility: 80,Altemate Fadllly: <br /> STERECYCL.E.INC. STERICYCLE.INC. STERICYCL.E INC. gTERICYCL.E,INC. <br /> LL 1345 Doolittle Drive.Suite C 4135W.Swift Avenue _ 90 Nora/1100 West 1612 Starr Dr <br /> L San L.eandro.CA 84577 Fresno.CA 93722 North Salt Lake,UT 84054 Yuba C' ,CA 95991 <br /> Z (510)562- 1781 (559)275-0994 (80 1)938- 1555 (530)755-0585 <br /> W TS3A.TS(OST25 TMST 22 Gtasswltlasetatinn Perlri*QA P-13,P-1A5 <br /> Pit TREATMENT FACT .I that i have been authorized t1 Ih estY Q cY to accept untreated medical wastes and that 1 have <br /> received th Indica asses in a ante with the requ' t Dyke n• orlon. <br /> oJr/ A4&'C'f R /�. r� '' JUL 3 4 2010 <br /> PrinVrype Mame Signature �� r'~+�� <br /> l Data <br /> i I <br /> 000 14 4 <br /> ORIGINAL rdf�elk:15o6sStd 2t+.tl <br />