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nx uat e/ t Ilse MAY-Zh-ZU11 (WED) 15: 35 <br /> 05/25/2011 WED 15: 53 FAx P. 032 <br /> 0032/049 <br /> 00 Steric & IN CASE OF EIIIRGENI CONTACT:CHEMTREC � <br /> STANDARD MANIFEST OBt•IoSTD <br /> +.•*o�..w.awer. Route <br /> 900^421-9300 MDRC0o-gKsx <br /> 1,Generator's Name,Address and Telephone Number <br /> ATTN: Gavle m4��� 111111111111 fill 1111111111 <br /> BIO/LORI MEMORIAL HOSPITAL <br /> 97S SOUTH FAIRMONT DRIVE <br /> LODI, CA 95240 <br /> (2091 334-3411 8/x712010 <br /> Cusrll Nuts <br /> Gsr1ERAT0Ra REctsraAraa r <br /> 2A•DESCRIPTION OF WAs7E 20 CONTAtNEA TYPE <br /> UN3291 Regulated M�f t 1DI 2C. No.OF 20, VOLUME <br /> 6.2.Poll IiC3T-Sr i' KR65 - Sala.systems Sharps xrans Cart (59 all ft) CONTAINERS <br /> Med <br /> UN329t,Repulaled kat waste.n.o.s.. <br /> 61,PGII MRSK - Bio3Vstema Tranvport Sox (4.3 cu ft) <br /> X UIY3191,RBlutated Medical Waste.n-o.8., CE <br /> 6.2,Pell <br /> uh13291 Reputate I Mel <br /> w4u.n'll Ct <br /> r s.z,pc;1i <br /> � UN3291.Regu4ted Medinr Waste.n.0.r.. <br /> � 6.2,P611 <br /> J�112,It RepukEeq Medical Wim,n.a.s.. G <br /> UN3il,A�utated Medical wage,n.o.s., q <br /> s,z.I'Gir <br /> UN3291,i10lubted Medical Waste,n.a.s., G <br /> 6 2.PGII <br /> 3.Q9neratel 0enitleatl0n:9 hereby declare that III Contents of ft consignment are Ivey and accurately T07AL$ Z�O` $y <br /> described above by the proper shipping name,end are classified,packaged.marked and label v d <br /> are in all respects in proper condition for Iran fed►glacarded,and <br /> i sport acc0rdtrtg to applicable International and national gove ntal reputations <br /> i �primed/r d Name <br /> 4.TRANSPORTER 1 ADgRESS: Signature pare ,r <br /> der Phone( 16) gt3S - 5506 <br /> Sc 121375 White ROCK 'dApp(Irmbla Permit NUMI ra <br /> a "+'S'>~RICYCLE Thin is a Through Shipment <br /> TRANSP[aRFR;M*PPQk Mteasdesc+ibed 11m i <br /> Print/lype Name Sklnatura- pate <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2ADDRESS <br /> Phone r: <br /> Applicabfa Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt m rrsad[val waste as describori above. <br /> PrinVtype Dame Signature <br /> Date <br /> 6.INTERMEDIATE HANDLER 3 iTRANSPORTER 3 ADDRESS: Phone r: <br /> Applkmbra Permit Numbers: <br /> INTERMEDIATE HANDLER ITRANSPORMR CERT1FICAT10N:Receipt a metlitet waste es <br /> zdescribed above. <br /> PrinVlype Name Signature Date <br /> 7.DISCREPANCY INDICATION p <br /> Transferred ` containers.0 .v b eu ft to : North Salt lake, UT <br /> Q 8A Lleslgt:elsd FadittYEIII Atlbmata Feeley: SC.A7ternata Faplly: Facll <br /> ANNE I- <br /> Sal" jool' e .ENG. �d W INC. p j�Ith 5�111►e 1 ffi4tr Dr 'fNC. <br /> 1 �+ oo!' a Drive.Stile C 1 W Avenue <br /> San Leandro.CA 84577 Fresno.CA 93722 North SaftLake,UT�qf) uba CA 95gs�1 <br /> (5 10)582-1781 0559)273-0904 (80 1)938. 1555 56$ JUYU <br /> TS3S.T'.19ST25 TMST 22 �:;las�V is txnet atia etTs id4 81 P-S.P-11 s 0585 <br /> TREATMENT FACILfTY: I certify that I have been authorized by the applicable state agency to untreated I w <br /> received the above indicated t accordance with the requirement outlin at a r as s and t t I have <br /> lion. � <br /> PrinVtypa Name Signature j- Date V <br /> 013474 <br />