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Rx Date/Time MAY-25-2011 (WED) 15: 35 P. 031 <br /> 05/25/2011 WED 15: 52 FAX 0031/049 <br /> 3terltyzle' !N CASE OF EMERGENCY CONTACT;CNEmTREC t*q&4e*&=L_ STANDARD MANIFEST 001.10-1*51'o <br /> • rr.ow•"•' ° Routr- #: 413 9 80D-424-83t30 MDRC00—gLZ7 <br /> 1.Generator's Name,Address and Telephone NuMber 8I9fI <br /> ATT11: G51,rle Most-, <br /> BIO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIPJ40NT DRIVE <br /> LODI , CA 95240 <br /> (209% 334-3411 913/2010 <br /> CUSMUER Nwarn 7—nQ7 GENEnATpR's Rr;QhrMAmoN 0 <br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 12C. NO.OF 21% YOLUSIE <br /> UN3291.Regulated M�p t�t� CONTAINERS <br /> 6.2,PGII OVUM' IM65 - Bin.".yzteum Sharps 1Yans Cars: (59 sru ft) <br /> 629291.Regulated Medical Waste,nv s, CL <br /> 62.PGII MR5E - 8io3Vsnrm.s Transport Box (4.3 cu ft) <br /> C UN3291 ReouWed Medial Waste,n.o.s., Ct <br /> ] 62,PGII <br /> Z UN3291.Regulated Medial Waste,n.Os.. C' <br /> r 0.2,Kit <br /> LI UN3291,Regulated Medical Wasl4,n.o.s <br /> 62,PGII <br /> UN3291Regulated Medw Waste,n.a.s., <br /> 6.2,PGli <br /> UN3291,Regulated Medk'al VOW,mos., Ol <br /> 6.2,15811 <br /> UN3291,Regulated Mewl Waste.n.os.. <br /> 6.2,PGH <br /> Ct <br /> RSBI <br /> S.Generator's Cortlticatlon:11 hereby declare that the COMet+ts 01 this consignment are fatly and accurately TOTALS F 20 5 <br /> described above by the proper shipping name.and are clauffied.packaged,marked and IabeltaWp carded,and <br /> are In all respects In proper condition for lmnspm according 10 appilcable inlemational and national gpvetnm rgal regulations' <br /> XPrintedrr Warne Signature Date�� <br /> 4.TRANSPORTER 1 ADDRESS: Phone M <br /> Appru ab a 6Pe)n Numbers:5 5 0 6 <br /> 11875 White 32aclC Rd <br /> N t3rl'f~RICYCsr ® Thit, is it Through Shipmcnb <br /> O� TRANSPOR' MFl 9fnVMl waste as dwjftd above, <br /> PrkwType Name Signature pate <br /> S.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: I Phone p; <br /> v <br /> App9cWe Parrntl Members: <br /> _ INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Rece€pi of medical waste as described above. <br /> PdrrVType Marne Signature Data <br /> u S.INTERMEDIATE HANDLER 3/TRANSPOSTER 3 ADDRESS: Phi 0: <br /> Applicable Permit Number&: <br /> E INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Remotol medal waste as aowi ed above. <br /> E PrinUtype Name Signature Data <br /> T.DISCREPANCY INDICATION <br /> Trans ed containers,��ou ft to : North Salt lake, UT <br /> GA.Desigeaeed Facility: BB.Alternate FadlKy: 9C.AkemMu Faetllty: 0.Allem to facilhy: <br /> STERICYCL E-INC. STERICYCL.E.INC. STERICYf0b. RICYCL.E,INC. <br /> 1345 Doolittle DrrvE.Suite C 4485 W.SWft Avenue 90 NorthVWV%st Ifflu Starr Dr <br /> San L.eandro.CA 84577 Fresno.CA 93722 North Sanake,UT 45t9 Y b CCA 95891 <br /> (510)502- 1781 (559)275-0994 (801,1838- 1555 � ( �-0585 <br /> TS31.TS(OST25 T510S'T 22 class Incicst' w% pa"74u#QAa 46 <br /> TREATMENT FACILITY:i ceriity that I have been authorized by the applicable ata a o accept led medical wast and that I have <br /> received the above indi s in accordance with the requireme ned in lian. <br /> Pr1ntlrype Nerve R Signature Rate <br /> 190 57 1 <br />