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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stericyde, IN CASE OF EMERGENCY CONTACT:CHEMTREC
<br /> rr.�.14 r+•.vr..""d"1p,�- 9i0 0 STANDARD MANIFEST 001.10-06•STD
<br /> I Route #: 413 � too-424-g3ot3 MDRC004]{g�
<br /> f 1. Generator's Name,Address and Telephone Number dd 11 #
<br /> ATTN: Gadle Moss
<br /> BIO/LODI MEMORIAL HOSPITAL
<br /> 975 SOUTH FAIRMONT DRIVE
<br /> LODI . CA 95240
<br /> (209} 334-3411 8/24/2010
<br /> CUSTOMER NUMBER (� 7-002 GENERATOR'S RratsiRA-noN f+
<br /> IE 2A.DESCRIPTION OF WASTE 20. CONTAINER TYPE
<br /> 2C.NO.OF 20. VOLUME
<br /> UN3291,Regulated M CONTAINERS
<br /> 6.2 PGI/ 9R65 - BioSysretas Sharps 'Trans Cart (39 Cu #'t)
<br /> UN3291,Regulated Medical Waste,ns.,.oCu Fr.
<br /> 6.2.PGII YLRBE - BiOSV5teut3 Transport Sox (4.2 cu ft)
<br /> IZ UN3291,Regulated Medical Waste,—.0 S., Ca FI.
<br /> 0 6.2,PGI/
<br /> UN3291,Regulated Medical Waste,n.a.S., Cu Ft.
<br /> 6,2,PGII
<br /> LU UN3291.Regulaled Medical Waste,n.o.s., Cu Fa,
<br /> tZ 6.2,PGII
<br /> t—
<br /> UN3291,Regulated Medical Waste,n,os., Fr.
<br /> 6.2,PGI
<br /> I Cu
<br /> UN3291,Regulated Medical Waste,n,o.s., Cu FI.
<br /> 6.2,PGII
<br /> UN3291,Regulated Medical Waste,n.os., Cu Ft,
<br /> 6.2,PG 11
<br /> RXBI cU Ft.
<br /> Cu R.
<br /> I 3.Generator's Certification:-f hereby declare that the contents of this consignment aro fully and accurately T07AL5 ►
<br /> described above by the proper shipping name,and are classified,packaged,marked and Fabelledlplacarded,and Cu Ft.
<br /> are In all respects to proper dition for transport according applicable international and natlonat governm 1 regul ti ns"
<br /> 1 — 'PrintedlTyped Nam —SignatureZ
<br /> 4.TRANSPORTER 1 ADDRESS: Date y �o
<br /> >-
<br /> Phone( lb) gas - 5,506
<br /> s 11875 White Rock Fid n Applicable Permit Numbers:
<br /> NSTERICYCLE In F s ie a Through Shipment
<br /> CL d TRANSPORTS IM and¢31pt I waste as described above.
<br /> fE
<br /> Print/Type Name Signalure
<br /> _ Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 A DRESS:
<br /> Q Phone 9::
<br /> NW
<br /> �
<br /> ON V
<br /> Appiicable Permit Numbers:
<br /> U9
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above..
<br /> Print/Type Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: ?hon© :
<br /> S Ix
<br /> Appticable Permit Numbers:
<br /> S g INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br /> N _
<br /> Pdntrrype Name Signature
<br /> Date
<br /> 7.DISCREPANCY INDICATION
<br /> Transferred containers, Cu ft to : Noah Salt lake, LIT
<br /> ❑8A.Designated Facility: 86.Alternate Faigilty: C
<br /> 8 .Alternate Faclll
<br /> ❑ b: ❑81).ARemate Faclllry:
<br /> U.c� STERICYC� INC. I YC INC. S7�RiCY INC. CY 1NC.
<br /> 1345 Doolittle Die.Suite C 41 SYAvenue 90 North 1WestBf2 Stare'
<br /> San L•eandro.CA 84577 Fresno.CA 83722 North Salt Lake,UT 84054 Yuba City.' CA 95991
<br /> f 5101 582- 1781 f559)275-0994 (80 4,)830- 15555301755-0585
<br /> `u TS3{,TSf05T25 MOST 22 Class+d trrines�ar. Fe^,it#9; �-2,fi-S15
<br /> Uj a
<br /> TREATMENT FACILITY: I certify that t have been authorized by the applicable tate a to accept untreated medical wastes and that I have
<br /> I-- received the abovein to teS in accordance with the requireme ed in crization.
<br /> Print/Type Name GSR Signature Date
<br /> /,a�,hnI
<br /> 00701
<br /> -- — ORIGINA1. rdf�cAlan50F4St� :t do
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