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• �u��� w� MA''Z3-6u11IwtV) ih: 3ti P. 034 <br /> 05/25/2011 WED 15: 53 FAX 0034/049 <br /> i 0 <br /> Stericycle'k CASE OF EAfERCEtJGY CONTACT:CFfE"EC .A-» STANDARD MMIFEST 001.104&-M <br /> • �`+• a•r�` Route #: 913 -e 800-4249300 <br /> �.Geheratcr's Name,Address and Telephone Number !L�R� (�q�NI <br /> ATTM: Gayle Mosee, <br /> BIOILODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LORI, CA 95240 <br /> 209 334-3411 0/1312010 <br /> CusTOKA NwtesR _ GElrEpATOp s R1sCteTMtgrrO <br /> 2A,DESCRIPTION OF WASTE 28. CONTAINER TYPE <br /> UM291 Reguiated 2C. NO.OF 20 VOLUME <br /> 6 2,PGdc -' M65 - >3i�os :cam $ <br /> coxrwr>sRs Q� <br /> p harp: T*Aw Gaa�t: (S9 CU ft) /7� Z. <br /> UN3291.ReOWHed Medial W ta,n.a.S.. G <br /> 0.21 Pail KRBB - BLoSyetems Transport Box (4,3 cu ft) <br /> jUN3291 <br /> 1112. Ragutated M edlal Vllasle,rt.o.S., G <br /> ccUN3291.Regulated T+ WWaste,&0,6., a <br /> 6.2,PGII <br /> U UN3291 Regulwed gut Writs,R.o.a. R <br /> 6.2,POti <br /> � UN3291.Ragtdated Medlgt Waste,lt.o.s_ O <br /> t;.2,P6i1 <br /> UN3291 Regl4w Medici Waste.rLos., A <br /> 6.2.A. <br /> 6�S29P0}}Regupted M t d Waste,rr.as., <br /> iRBBI G <br /> Az 5.0 <br /> 3.Ganerotor's Certftlr atlon.-1 hereby declare that the contents of this comignmertt are fully and accurately TOTALS <br /> deSCrlbetl 00"by Ute proper aftfppbtg name,ware dassired,packaged.marked and is <br /> be] and A <br /> are In all respects in proper corKNoonrfor <br /> rttransport eosarding 10 appikabte international and natlona!govgmental reguta�6o�rts/.' <br /> ( � �pdName _.. .3ignatur Q�i�' •� <br /> 4.TRANSPORTER t ADDRESS: Date <br /> t'hona116) Sas - 5506 <br /> 11075 White Rock Rd APpitcabla Permt!Numbers: <br /> g STERICYCJ&E 77tis is a Through Shipment <br /> fA <br /> TRANSPORI' q 1lrke t waste as desplbad above. <br /> 11 <br /> Pfi tVrype Name ./�./O <br /> Signature Date (� <br /> rr 5-INTERMEDIATE HANDLER 21 TRANSPOATER 2 ADDRESS: Phone#: <br /> ry Applicable Permit Numbers; <br /> ' INTERMEDIATE HANDLER 1 TRANSPORTER CERTIFICATION:ReOW of madaat waste as desoribed above. <br /> PrbWType Name Signature tyle <br /> s B.ENTERMEDIATE HANDLER 3I TRANSPORTEEM 3 ADDRESS: Phone a <br /> Gi Applicabla Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTEI:R CER'TIFICA71ON:fiewipt of medtret waste as described above. <br /> Printrrype Name Signature Data <br /> T.DISCREPANCY tN01CA1(gN <br /> Transferred Da-containers. 3—S-40cu #t to : North Salt lake, UT <br /> ❑SA.O"natea Faciaty: ft Aitamate Facility: <br /> 98c.Allamaro F eN �„ R. a Fad] <br /> aY• <br /> �CYIiVG. AlvNenue BQ Forth 9 Wei �tarr 'INC. <br /> Do a r1ve.Suite C ((�� � <br /> San Leandm.CA 64577 Fresno.GA 83722 North Salt Lake ��Yuba C�'y CA 95891 <br /> r51 Q)662-1781 Ox8)275-GM @01�938. f a515� 530)765-0565 <br /> TS31.TwST2t TSMST 22 1at s i�Inainesa+d Qe 91 p-115 <br /> pa <br /> TREATMENT FAC¢ _; I certify that 1 have been authorized by the afe a ency to accept untreated M Ica E w <br /> received thea i waS1eS in accordance with the r!;G <br /> authorizattion: les an that 1 haveSignatu <br /> Date <br /> {�F G <br /> so <br />