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MEDICAL WASTE TRACKING FORM NUMBER
<br /> @• 5t0riCyd@' IN gASY. F.M GMCY CONTACT��BMT;t3EC gg�_ &T n3 g� r�ANIFEST 007.10-6&STO
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<br /> 1. Generator's Name,Address and Telephone Number Ill I in II!1I i11 9 1111 11 1 1 111 1 II 1I 1119 IMI 1
<br /> 1\mPTrr.
<br /> Yra�,i M„oa G 1iI 11�111t1pi1H111111911191111RI11111111@ 1111 gII €
<br /> " ' r'+ "u` j` "w %-,d 111 11116111111111@1111119111191161011111 fold g11 1
<br /> BIO/LODI MEMORIAL HOSPITAL
<br /> 975 SOUTH FAIRMONT DRIVE
<br /> LODI . CA 95240
<br /> (209) 334-3411 5/10/2010
<br /> CUSTOMER NUMBER r,A R 4 r1+7 7-0 0 . GENERA7OR'S REwa7RAT*N e
<br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO.OF 20. VOLUME
<br /> UN3291,Regulated Medial Vilest,rtes, r, CONTAINERS
<br /> 6,2,PGII tt -SN A%, 1CR$5 - Eiooystcws Shaxps Trans Cart (59 cu ft)
<br /> UN3291,Regulated Medical Waste,n.os., Cu FI.
<br /> R 6.2,PGII KRB% - Bio$vztemz Tranatsort Box (4.3 au ft)
<br /> 0 6 2.PGII Regulated Medical Waste,n.o.s..
<br /> Cu Ft.
<br /> l Cu FI,
<br /> Q 1323291,Regulated Medical Waste,n.os.,
<br /> � 6.2.PGII Cu Fr,
<br /> W UN3291,Regulate
<br /> LU Medical Waste,n.0.s.,
<br /> 6.2,PGI!
<br /> 11 CD UN3291,Regulated Medical Wasle,n.o-s.,
<br /> Cu Ft.
<br /> 6.2,P01I
<br /> UN3291,Regulated Medical Waste,n.os.,
<br /> Cu FL
<br /> 6.2,PGII
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> Cu Ft.
<br /> 6.2,PGII
<br /> Cu Ft.
<br /> RS$Y
<br /> Cu FI.
<br /> 3.Generators Certification:"I Hereby declare that the contents or this consignment are fully and accurately
<br /> TOTALS ►
<br /> described above by the proper shipping name,and are classified,packaged,narked and labellsdlplacarded,and Cu Ft.
<br /> are in all respects In proper Condition for transport according t applicable international and national governmental regulations'
<br /> IPrinfed(ryped Name&U4.4 Si nalure Date to
<br /> I, cc 4.TRANSPORTER 1 ADDRESS: Phone(ri15) 995 _ 5,506
<br /> Q11875 WhiteRockRd � Applicable Permit Numbom
<br /> g N �'PERTC'[�LE X Thin i3 a Through 3hipmcnt
<br /> Q TRANSPOR TIFICAT t ale wade as described a
<br /> cc
<br /> Prini/T j
<br /> ype Name Signature Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2ADDRESS: Phone#:
<br /> Applicable Permit Numbers:
<br /> RID
<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: Phone#:
<br /> o Applicable Permit Numbeis:
<br /> UR 2 INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION:Rgcelpt of medical waste as described above,
<br /> zL
<br /> Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Trans fa ed containers, ul ft to : North Salt lake, UT
<br /> ❑8A,Designated Facility: 9,Altemate Faatlity; Lj SC,Alternate Facillty: E] aD.Anernats Facillty;
<br /> J �
<br /> U STERlGYCLE.ItVC- STERICYCLE.INC. STERICYCLE.INC. STERICYCLE,INC.
<br /> LL 1345 Doolittle Drive.Suite G 9135 W.SwittAvenue 90 North 1100 West 1812 Starr Dr
<br /> 19 San Leandro.CA 94577 Fresno.CA 93722 North Sah Lake,UT 84054 Yuba City,CA 95991
<br /> .(610.1602- 1781 (5591 275-0994 fa0 t 1938- 1555 (530) 755-0585 .
<br /> "iS3S.T5i�ST[8 `MOST CtasstJira%emttart FeriTit#38t P-d,IP-tt5
<br /> TREATMENT FACILITY: I cerci that I have been authorized b the livable sta
<br /> rs certify y pp gene t 'a cept Untreated medical waste and that I have
<br /> !•- received the above indicate St accordancewiththe requirement o In that
<br /> PrinUType Name �GRSignature +r Date
<br /> ao pis
<br /> ORIGINAL
<br />
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