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ILA yauc/ 1IRG RAI-L7-611111WCllJ 1h: 3h p 033 <br /> 05/25/2011 WED 15: 53 FAX 12033/049 <br /> ���� SteWcycle' tN CASE OF EMI:RC3jENCY CONTACT:CHEMTHE STAINt�ArtD MANIFEST flot.faoe sTo <br /> Route #: 43.3 eno-qac s3 0 MDAC,00913I9 <br /> 1.Oerterator's Name, 1 <br /> Telephone Number Address and AddrTli 1Ed Ill 1 11 Ifl 1 ( �� <br /> ATT�:: Gavledoses �� I � III I al <br /> BIO/LORI MEMORIAL HOSPITAL <br /> 975 SOUTH F'AIRMONT DRIVE <br /> LODI . CA 95240 <br /> 20� 334-3411 8/20/2010 <br /> CusTom-"� � aF.mmmn's ReGmTRATroa R <br /> 2A.DESCRWTiON OF WASTE 2B. CONTAINER TYPE 2C.ND OF 21). VOLUME <br /> UN3291 Regulated Medlml Waste. , .s., CONTA ERS <br /> &2,pet[ DOT-SP 13 8 F3t6S - 31037stems ShArps Trans Cart (S9 cu ft) ! .� <br /> UN3291 Regulated Medical Ot <br /> Waste,n.o s., <br /> 6.2,Pali )MIN - Bio3Vstem5 Tranoport Box (4.3 cu ft) <br /> Z Ut13291,Regulated Med€cal waste,n.o.s., Cc <br /> 6.2,PGII <br /> C 8U.2,PGJI N329i.Regu <br /> xlated Medical Waste,nA.s, CL <br /> 11 UN3291,Repulated Medkal Waste,n,o,s. LR <br /> 6.2,FG11 <br /> UN3291 Regulated MotdkW Waste,n,os„ tit <br /> &2.PGI <br /> 0291 Regutated M(W , G <br /> FGII 14lras%n.o.s. <br /> =291 RegWated Medka!Waste,n.o.s., Ci <br /> 6.2.PGII <br /> et <br /> RXBI 1, (044 <br /> ddescribeddescribed above by the 9 <br /> Ct <br /> 3.Gerwow'e Certlflcaftn:"I hereby declare that the cCgtt9rtts of this oanslpnment are fully and accurately TOTALS ► <br /> proer pshipping name,and are cfassilted,packaged,marked and]abeftedlplacarda" and Ci <br /> are In all respects.in Proper co tion fon transport according applicable ktlernatfonal and national <br /> Bole a!ragutatlorts; <br /> X1PdZqgM2Led Name SI nature Date <br /> 4.TRANSPORTER 1 ADDRESS: <br /> B5 5SD6 <br /> Phone " <br /> 11875 White Rook Rd 1��Numbe <br /> i STERICYCL'E Thia/a a Through Shipment. <br /> �q TRANSP0RTF"qgj3 :f} g waste as devAbed abop. <br /> Print/Type Name lid- <br /> 8lgnaturo � <br /> 5.INTERMEDIATE HANDLEfi 2!T SPORTER 2 AD KESS: t'hcne R <br /> Applicaf�le Pennts Numbers: <br /> INTERMEDIATE HANDLER MANSPORTER CERTI <br /> FICATJON:Receipt 01 medksf waste as described above. <br /> Pdal/Type Name Signature Date <br /> Sg 6.iM ERMEDIATE HANDLER 3/TRANSPORTFA 7 ADDRESS. Phone 0: <br /> u-F Applicable Pttmlt Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recetpt of medical waste as descrbed above. <br /> Prinvrwe Name Signalure Date <br /> T.DISCREPANCY INDICATION r []' <br /> Transferred IS containers. 'b cu ft to . North Sall lake,UT <br /> WL Deafgnated Fee9 <br /> & dY• ell.Ahernate r�lty; 8t:,ARonuta Fadtity: Facility: <br /> & STERICYCtE.IIVC. �aTERIGYCLE.INC. S'IERi <br /> STERICYCLE,INC. <br /> 1346 Doolittle Drive:Suits C 4135 W.Swift Avenue 90 No i West 16112 Starr Or <br /> San Leandro.CA 84577 Fresno.CA 93722 North Salt.Lake,UT Q�QYuba C' ,CA 95981 <br /> (510)502- 1781 65k)275-0904 � <br /> ( l8©i 1838- 1555 U f 531)175 -0585 <br /> TS31.TS*ST25 MOST 22 Class V lnoinersdan PerZd4g�v <br /> - P-116 <br /> TREATMENT FACILITY:l certify that 1 have been authorized try the applicable state agency to a ast <br /> es recelved the above i t7es In accordance with the requirement outll ed in th I horiz� and that!have <br /> PrbntrType Nama� } <br /> Signawre Date rev <br /> 00678 <br />