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Rx Date/Time MAY-25-2011 (WED} 15: 35 P. 047 <br /> 05/25/2011 WED 15: 57 FAX 2097/049 <br /> 0 norar t*kt t IN CASE:OF EMERGENCY CONTACT:CHEMTREC 14t0�986G—. STANDARD MANIFEST Domo- sm <br /> • �o+.�y w.oa•�a� <br /> Route #: 412 -0 Cuatomer No.21132 MIIRCOO9 CD <br /> 1.Generator's Nance,Address and Telephone Number II f I <br /> . ATTN: Gale Moses �III���I�I�II��I �1�I�III�I�DI�� I��IlII�III �I��I� <br /> BIO/LODI MEMORIAL WEST CAMPUS <br /> 800 SOUTH LOWSR SACRAMENTO ROD <br /> LODI, CA 95242 <br /> (209) 339-7666 9/24/2010 <br /> CUStOWA NUMBER 60890'77-003 •• GEREMTORs REawrRamm 9 <br /> 2A.DESCR497WN OF WASTE 213. CONTAINER TYPE 20.NO.OF 2D. VOLUME <br /> UN3291Regtdated MIORMe1 RR65 - SioSystcros &harps Trans Cart (54 Cu ft) CONTAINERS <br /> $.2,PH <br /> 1111141,Regulated Medical Wasta,A&S., <br /> 6.Y,PG4 Sfo3vacema Tranaport Box (4.3 au ft) <br /> C Uft3291 Regulated Medical W051e,11.0.5.. • C. <br /> 6.2,PGI I <br /> r <br /> 123P22I1 Reglrlaled Medical Waste.moa.. d <br /> M UN3291. Wulatod Medical Waste,n.o.s.. <br /> z 5.2,Poll <br /> UN3291,Regutale0 Medkal Waste,Mo.&. <br /> $.2,PO-11 <br /> UN3291,Regulated Medkal Waste,n-0.s, CA <br /> 6.2,Pal <br /> UN3291 Requbfad fdadkak Waste n.o s, <br /> 6.2,PGI( <br /> CA <br /> 9.fienerator s I ttlffeatfon:•a hereby declare filet the Contents of this consignment are fully and a0mmeffyy TOTALS ► <br /> described above by the proper 5110PIng name,and are Classified,packaged.mantad and labeltedrplacarded,and <br /> are In all respects In proper oonstitlat for transport n to applicable inlernational and national Bove aM81 etlons• <br /> JX' <br /> f Prfnl ed Name 1 Signa Date r <br /> 4.TRANSPORTER 1 ADDRESS: <br /> pt"ix�1$) 985 - 5506 <br /> 11875 White Rook Rel � �pl�blePermitNumbers: <br /> O STERICYCLE LJ `1'hia in a Through Shipment: <br /> TRANSPO�Fl�,A I waste as described ab9m. ' <br /> Prinllfype Name Signaturer2�.�Q <br /> S.INTERMEDIATE HANDLER 2/ ORTER 2 ADDafe <br /> DRESS: te s: <br /> as <br /> Applicable Pa►mit Numbers: <br /> INT'ERMEDIAT'E HANDLER/TRANSPORTER CER71FICATlON:Recetpi sal medical waste as described above. <br /> l; <br /> Pr WTi pe Name 8lgrtature Date <br /> U 6.INTERMEDIATE HANDLER 3 ITRANSPOFtrER 3 ADDRESS: Phone N: <br /> iApplicable Permit NumbBrs: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICA71ON:Receipt a mudicel waste as described abm. <br /> H Prinafrype Name - ' $tgnasure Date <br /> 7.DISCAEPANCY INDICATION <br /> Transferred Q ountains:t's, ��txl ft to : North Salt lake, UT <br /> ❑BA.Dealgnated Fedthp BS.Alternate Facalty. 86,Anemate Pwitty: 80.Alternate Facility; <br /> STERICYCLE.INC. ITERICYCL .INC. STEM CYCLE.INC. STERICYCLE.INC. <br /> 1: 15 nAfki t#n r)rivo Staha t- 4135 W.SWftAvenue g0 North 1100 West 1012 Starr Or <br /> flan 1 Panrlrn rA A4577 Fraaut r A 01771 <br /> North Salt Lake UT 84054 Yuba City.CA 95391 <br /> (5101562- 1781 1569)275.0994 (801)Q38-1656. P <br /> (5301755.0585 <br /> TSRi T.�fl yST74 TSlOST 22 �Igs M Ir WEEP �f P-6,P-115 <br /> p O �b <br /> TREATMENT FACILITY:l certify that I have been authorized by the applicable stale igen ��tnn � ated medical waste and that I have <br /> received the above In es;in accordance with the requiremeA�oulflrn lit tha ri �L <br /> Prinalrype Name Signature pat <br /> (3Q4$ r <br />