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4111:0.00 <br /> MEDICAL WASTE TRACKING FORM NUMBER <br /> �r Stericytle' IN CASE OF EMERGENCY CONTACT:CFiEMTREC 1 app-424�ggg STANDARD MANIFEST opt-i 0-06-STo <br /> • ''°"�°' "Ri°�°"h' Route #: 413 -0 500-424-9300 MDRC009K71 <br /> 9.Generator's Name,Address and Telephone Number f <br /> ATTN: Gayle Mises <br /> BIO/LODI MEMORIAL WEST CAMPUS <br /> '800 ZOUTH VVER SkCRMiZ13T0 ROD <br /> LODI. CA 95242 <br /> E2091 339-766 8/24/2010 <br /> CUSTOMER NutiaeR n 1R 9 7_ GENERATOR'S REGISTRATION 9 <br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO.OF 21). VOLUME <br /> UN3291,Regulated M i l Wa t@,�n�Q� CONTAINERS <br /> 6.2,PGII OOT-v 1,iS5 " IR65 - SioSystems Shnrps Trans Cart (59 cu ft) <br /> UN3291,RegUated Medical Waste,R.o.s., Cu Ft. <br /> 6.2,PGII KRBB - 5iO3pszems Tran!%port Box (4.3 cu 1:t) <br /> M UN3291,Regulated Medical Waste,n.o.s„ CU Fl. <br /> 06.2.PGII <br /> Q UN3291,Regulated Medical waste,n.p.s.. Cu Ft, <br /> 6.2,PGII <br /> ILI UN3291,Regulated Medical waste,n.o.s.. Cu Fs. <br /> Z 6.2,PGII <br /> LUN3291,Regulated Medical waste,n.o.s., Cu Fi. <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,n.o.s.. Cu Ft. <br /> 6.2,PGII <br /> UN3291,Regulated Medlcal Waste,n.o.s„ Cu Fr. <br /> 6.2,PGII <br /> Cu FI. <br /> RXBT <br /> Cu FI. <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are lully and accurately TOTALS ' <br /> described above by the proper shipping name,and are classified,packaged,marked and Iabeilod/placarded,and Cu FI. <br /> ars in all respects In proper di6on for transport according applicable international and national govern I regul tions" �y �, <br /> flPrinted/T ped Name Signature �C�� J pate �l <br /> tr 4.TRANSPORTER 1 ADDRESS: <br /> w Phone <br /> #: <br /> • <br /> 11575 White Rock Rd Applicable Permit(ql6) 99Numbers:5 - ­5(113 <br /> 2N 13 TER `�x� j!5 a Through Shipment <br /> f ¢a d TRANSPORTE&GEEMFIGAT W41 B5TZc9&i waste as described a <br /> f <br /> ~ Prin <br /> Illype NameSignature '12 r <br /> Date <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADIDRIES& Phone q: <br /> Applicable Permit Numbers: <br /> g INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt or medical waste as described above. <br /> Print/Type Name Signature <br /> Dale <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: <br /> a a� Phone#: <br /> Applicable Permit Numbers: <br /> z INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, <br /> s�= <br /> I Printrrype Name <br /> Signature 9 Dale <br /> i 7.DISCREPANCY INDICATION <br /> I <br /> Transfe ,ed containers, cu ft to : North Salt lake, UT <br /> � SA.Designated Facia�❑ 9 ty: I3.Attemate Facility; ❑SC.Akemate Facility; BD.Allemete Faculty: <br /> U< STERICYCLE.INC, STERICYCLE.INC. STERICYCLE,INC. STERICYCLE,INC. <br /> U< 1:�4.ri rinniittlo I7riwp grritp f 4135 W.Sw tA�+enue 90 Notch 1100 West 1812 StaiT Dr <br /> Z g ran I P;;nrirn CA 174577 1"rpmn rA 0779 North Salt Lake,UT 84054 Yuba City,CA 85991 <br /> W (5101552- 1781 (5-591275-04?4 (80 1)936- 1555 (530)755-0585 <br /> TRII TGf()tiT7..5 MOST 22 Class`J Inr_iner don Perm-at#91 P-6,P-115 <br /> TREATMENT FACILITY certify that I have been authorized by the applicable state a e to accept untreated medical wastes and that I have <br /> I- received the scat rtes in accordance with the requireme 1 ed in horization. <br /> ' 7AGpE i2 <br /> Printli]rpe Namb• �� � �t Sigrtaiare Date <br /> 00702 <br /> ORIGINAL <br />