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Rx Date/Time MAY-25-2011 (WED) 15: 35 P. 029 <br /> 05/25/2011 WED 15: 52 FAX 2029/049 <br /> 5tericycle, <br /> • '""°''�^ ► m� 1N CASTF EM RGI CY CoNTACuT,aCHtE�mC Route : 93 to.2 3ja" STANDALRD ANF $r 001•144i• DGLA <br /> 1•Generator's Name,Address and Telephone Number ll (lU 9l I r� � <br /> m � 1YI a :����� , I9I1ili� Il19� 9, 1®1; 1a <br /> BIO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> (2091 334-3411 9/2412010 <br /> G1S1Z1MEA f1VMBEa Q QE NFPA70W8 REGWMAMN I <br /> 2A.DESCRIPTION OF WASTE 20. CONTAINER TYPE 2C. NO.OF 20. VOLUME <br /> UN SI ReguWad MedWI Waste n.o.ffi CONTAINERS <br /> 6.2,PGE1 DOT-SP 13556 ER65 — Biasystem Shazgs Mans Cart (59 cu £t) <br /> UN3291,Regubted Medical Waste,mos, 0 <br /> 02,Poll WX — Bi03VVttme Transport Box (4.3 ata it) <br /> = UN3291 Regulated Medical Waste,o.as., C <br /> ] 6.2,poll i <br /> UN3291,Regulaw Medlcaf waste.n affi_ C <br /> 6.2,Poll <br /> LI UN3291,Regulated Medical Waste,n e.ffi„ C <br /> a 6.2,PGS! <br /> UN3291.Regubmd Medical Waste ao.s C <br /> 5.2,f'Gtl <br /> U1413291 Regulated Medkal Waste.n.a1" C <br /> 6.2,Poll <br /> UN3291,Regulated Medical Waste,n.a.e., C <br /> s.z,PGp <br /> RISB= 7 <br /> 3.Generator's Certification;I tweby declare that the conlenis of this consignment are lolly and accurately TOTALSAl 5 <br /> described above by the proper stripping name.and are classified,packaged,madced and tabelleftlacwded,and ' C <br /> are In all respants in proper d'dfon for tmonsport according to applicable laternalional and national govemm ntal r attong' <br /> I <br /> 'Print <br /> Na 5i nature Date '�� <br /> Y 4.TRANSPORTER 1 ADDRESS: <br /> ;F+r <br /> phone 3l5)md.t8;3 ^ 5506 <br /> :O 11576 White Rook Rd Av a rumbers <br /> :c. 5TERICYCL� 'Phis t5 a Through 3fliplaent <br /> �j TRANSPORTS 0A #tp=cj f9tltlll8l waste as deealbad above, <br /> Prim/Type Name ftnawre `�` Date •�!� <br /> 5.INTERMEO ATE HANDLER 21 TRAIVSPoRTFR 2 DRESS: Phone tl: <br /> Applicable Porm ll Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIMATION:Receipt of mads r <br /> �P Ca waste as described above. <br /> Pi intrlype Name 619naturs Data <br /> 12 6.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone if: <br /> I r` ApPloobta Pem%Numbers: <br /> INTERMEDIATE HANDLER/TAANSPORTER CERTIFICAMON:Receipt of medical waste as described abova. <br /> z <br /> PrinUTyps Name Signature Data <br /> 7.DISCREPANCY INDICATION ^ J� <br /> Transferred�' ! containers, _Y4,0cu it to : North Salt IUP. <br /> ❑8A.Designated Fadift: Be.Alramete Faculty: BC.Allemate Fall male faculty <br /> STSRICYCLE.INC. STERICYCLE.INC. STERICYCLE,INC. Y <br /> 1345 Doolittle Drive.Suite C 4135 W.Swift Avenue 80 North 1100 West or—j 8 <br /> 6try rfCtLE.[NC. <br /> San Leandm.CA 94577 Fresno.CA 93722 North Saft Sake,UT 84054 Yub CiCA 95991 <br /> f 5101562- 1761 (559)275-0894 f 8011936- 1555 9 1 0585 <br /> i.TS(OST25 TS(©ST 22 6as`s V Indneraoon P�Qvat <br /> flit. TREATMENT FACILITY,I certify that I have bean authorized by the applicable state agency to cre;:Date <br /> medical waste nd a1 I have <br /> rOCeived the above indicated wastes in accordance with the requirement outlined In that a tio <br /> PdnvlType Name Signature <br /> D104:36 i <br /> narr_rarar <br />