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Rx Date/Time MAY-25-2011 (WED) 15: 35 030 <br /> 05/25/2011 WED 15: 52 FAX 2030/049 P.P. 030 <br /> iii 5terltytle: O <br /> �� 'O'•�'v" •'id" "'�' RautAQSE F! G CYCOtITACTi ff5 7AECt.�— STAN DMANIFESTaaj•tpa6.aTo <br /> U' �E4 KWIC0090FC, <br /> 1.Generator`s Name Address and Telephone Nurrlber <br /> TT vltsr�,e Mo�e� ��i�� ��������������� ������� �������������� � <br /> B �4RIAL HOSPITAL <br /> IOlLODI M <br /> 975 SOUTH FAIRMONT DRIVE <br /> ,ODI- CA,r 95240 <br /> (209 334-3411 9/1712010 <br /> CUsrom£R NUMBER _ <br /> 002 GENERATOR-5 REWaTRAMON <br /> 2A.DESCRIPTION OF WASTE 201 CdNT1UN>R TYPE <br /> UN3291 RvWIWd M ►p�y� �p�. 2C.NO.OF 2D. VOLUME <br /> &2,PGII -SPsi.x�o KR63 - SRaSpstams Shasps TZ"s Cart (S9 Cu £t) CONTAlN$R9 <br /> ,PGF gulated Re <br /> &2Medical Wasee,m.o.a.. 2- Cr <br /> 6 2,POf� FWX _ BieSV5tetas Trartaport Box (4.3 au it) <br /> UN3291 j Regulated Medical waste,n.o.s.,6.2,PGtICc <br /> UN3291.Regulated Medea!waste,n.as„ Cr <br /> &2,PGII <br /> UN329t. <br /> PGI!Regulated Medical was",n.o.s., Cr <br /> q UN3291,Regulated Medical Waste,FLO.s., cti <br /> &.2,Poll <br /> UN3291,Regulated iNedlral Uyasle,n.a.s, 216.2,PGII <br /> UN3291 Regulated <br /> N291Regulated Medica!waste,rms,62.PG11 <br /> Cr <br /> A8>3Z G <br /> G <br /> 3.Generator's CerUllcatlon:'t he dedem that the conlents 01 this c:ortaignment are Cully and amrelely TOTALS ► <br /> described above by the proper shipping name.OW are dassltied.Packaged.marked and lebeg G <br /> are In 6f1 respects In PmPer cion for twisppn according to a Usable International and national govam in tatPons. <br /> Printedrryped Name 12� Signatu -7'lb <br /> 4.TRANSPORTER t ADDRESS: <br /> PhO1et916) 998 — 8546 <br /> p <br /> 11876 wh i to hark Std APOHMNs Permit Numbers: <br /> ttn tiT£RICYCLt3 Thiti •L' a Through Shipment <br /> TRANSPORTfiR IMATIp co t„ 19 as dascrmed atom <br /> PrinVType Name Signature Oats -I <br /> 8.INTEflME_DIATE HANDLERTR <br /> 2/TRANSPORTER 2 ADDRESS: Phoma t: <br /> AW1cable Permp Numbers: <br /> ., INTERMEDIATE HANDLER/TRANSPOFITER CERTIFICATION:Receipt or medical waste as desrxlhed above. <br /> PrInllType Name Signature Date <br /> r• G.INTERMEDIATE HANDLER 31 TRANSPORTER 3ADDRE5S: <br /> c Pitons r!. <br /> APP00"Pam*Numbers: <br /> INTERMEDIATE HANDIER/TRANSPORTER CERTIFICATION:ROWIP1 of medical waste as described above. <br /> PrinV Wm Name Signature Dale <br /> 7.DISCREPANCY INDICATION p <br /> 'Transferred�comtainers, logo Ou ft to ; North Salt Iakp,Lr <br /> 0 6A.D9Mj;-sted Feclltty: Wee.A:tmrete Faclety <br /> •A,Itprttete FeclN�. � Eb.Alflmata FaciUty; <br /> STERICYCLE.INC. SIERICYCLE.INC. STE�,INC. � STERICYCLE,ING. <br /> 1345 DaoGttle Drive.Suite C 4133 W.5v�*Avenue Bfl North 1 f QO We �- f @12 Starr Dr <br /> San Let3ndro.CA 89577 Fresno•CA $3722 Narttl Soh L�1ce,k��g05A Yuba C' ,CA 95991 <br /> {51t},15t32- 176E X5591275-OBB4 (80 1)938- 1355 Q3 75W x585 <br /> TS31.TS(OST25 TStOST 22 Cass V trdnePt <br /> TREATMENT FACILITY: 1 certity that I have been authorized by the applicable state agency to ecepl untreated medici"--- <br /> ----------- <br /> ID <br /> ste <br /> received the above ind[Wed aste in aocordance with the requirement outline that a ation. s a d that have <br /> PrintfType Name Signature Date q t/ <br /> 0+417 <br />