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LLA 11AI,G/ LIEU 17. 37 P. U35 <br /> 05/25/2011 WED 15: 54 FAX 12035/049 <br /> 000 6tericytle IN AS FCY STAN ARC)MANIFEST cot-*WSTo <br /> • �a-� w�: Rou a �� CONTACT8 � ' HDRCl1Ci HGG <br /> 1.Generator's Name,Address andTelephone Number 1115111 111, <br /> fflo hTT";. ,µp11 11 ��fitI111111111 <br /> BIO/LORI MEMORIAL HOSPITAL <br /> 975 SOUTH FAI RMONT DRIVE <br /> LODI. CA 95240 <br /> (209) 334-3411 8/6/2010 <br /> CUSTO&WR Nuteae p 7—0 0 2 f3E7iMTows FlmsTmnonIt <br /> 2A.DESCRtMON OF WASTE 26. CONTAINER TYPE ZC. NO,OF ZD. VOLUME <br /> UN3291 RagutatedCONTAINERS <br /> rl . <br /> $1.?GII ' IM65 - Blo5ystems Shazps Tums Cart (59 cap ft) d <br /> UN3291 Regulated Med1w Waste,n.o.s., <br /> 6.2.PGfI 1=1 - Bio3vstem3 Tranmport Box (4.3 cu ft) <br /> 7 6�G11I Regulated Medica!Waste,n.o.s <br /> c� <br /> Q UN3291 Regutaud Medical Wasto.rr.o.s., <br /> a <br /> r 6.2.PGII <br /> 13 UN3291 Regulated Med Waste.nx.s., d <br /> z 6.2 ,PG11 G <br /> UNS291 RMWW Medica!Waste.tws., <br /> 6.2.Poll <br /> 6 23 Gt I Regulated Merles!Wade,n.as., <br /> UN3291 Regulated lltadical Waste, <br /> G <br /> 5.2.PGti <br /> d <br /> RXB1 -72 <br /> 3.Generator's Cartifterflon:11 herohy dectara that the contents of this oonsignment are fatly and accurate <br /> 2— <br /> �q „ <br /> OescdW4 above by the proper shfpping name,and are classified,packaged6 marked and tabelled! L <br /> are Ina!1 respects In proper condition for transport according to appiiratrie international and natio gone to ris <br /> I (vi <br /> I r lPrinted(Typed Nam na Date <br /> 4.7RANSf TORTE R 1 ArsAHESS: PhoneA 16) 985 — S606 <br /> 1187.5 White: Rork Rd AppliCabie Permil Numbers: <br /> S'i'£AIe5fC1,E Thio is Through Shipment <br /> Th <br /> T S$,Wgal waste as dawrlbed above. Q /� <br /> PrinUType Name Signature Date <br /> 6.INTER,MEDEATE HANDLER 2/TRANSPORTO 2 ADDS ESS: Phone ll: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as dascribed above. <br /> Prfnt/Type Name Signature Data <br /> 6,INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone M: <br /> Applicable Permit Numbers: <br /> 2 INTERMEDIATE=HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as desaibw above. <br /> Print/type Name Signature Dale <br /> T.DtSCRi=PANCY IND1CATi0t+t Q <br /> Transferred oon#ainers, ! - aZ cu It to : North Sall lake. LIT <br /> Q 8A.Doognated Facility- 8B.Attarnafa FacflltyL Kj 8C.Alternate Feeiliy: Facility: <br /> STERICYCLE.INC. STERI CYCLE.INC, STE7N�`��� STEwRICYCLE INC. <br /> 1345 Doolittle Drive.Suite C 4135 W.Swift Avenue $0 North 1100 West 1812 Starr Or <br /> San Leandro.CA 94577 Fresno.CA 93722 North Salt Lake, �� Yuba C ,CA 95991 <br /> (5101 582-1781 (559)275-0994 {8011938- 156 ., {5301755.0585 <br /> TS2i.TS(OST25 MOST 22 Classy Ircdnesation Pem-&at P-8,P-1 1S <br /> r� <br /> TREATMENT FACILITY:I certify that I have been authorized by the applicable state age 448cand I wastes and that I have <br /> received the agave lndicaa Ps.,In accordance with the requirement ou n th rization, <br /> Signature DatePrrntllyAe Nemo _ b <br /> u314 <br />