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Rx Date/Time MAY-25-2011IWED) 15: 35 P. 028 <br /> 05/25/2011 WED 15: 51 FAX 2028/049 i <br /> WO-0 Sterlcycle- 1N CASE OF EMERGENCY CONTACT:CHEMYREC-dfur o fNIFE6T DDt•tp 66YDe : : Ustoaec 41MIT? MDRCS <br /> 4.Penerator's Narne,Address and Telephone Number <br /> BIOILODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> 209 334--3411 10/112010 <br /> CUSTOMER NUMBER 60900 OWEAM31T REmsrgnnorre <br /> 2A.DESCRIPTION OFWKS-TE- 21b. CONTAINERTYPE 2C.NOOF 20, VOLUM@ <br /> UN3291 Regulated Mediad waste,a.o.s„ CONTAINER8 <br /> IM-65 - BiaS steals Sha=c Tracts Cart (59 ca ft) C <br /> IJW" Regulated MOW waste,a.as., <br /> iQt8X - BioS stems Transport Box (4.3 cru ft) C <br /> X 6.Z N 91 Regulated Medial Waste,nos., <br /> Q UN3291 Regulated Medical waste,nox, C <br /> r 6.z,Pail <br /> ILI L€ UN3291 Regulated Medical Waste,n.o.s., C <br /> 6.2,PGI! <br /> 11N3291Regulated Media !Neste <br /> Medical n.aL, C <br /> 6.2,PGII <br /> IINS291 Regulated Medial Waste,B.o.s„ C <br /> 6.2,PGii <br /> UN3291 Regulated Medical Waste."I. C <br /> 6.2,PGII <br /> C <br /> 3.Generatorla CertI fcatton:'l hereby declare that the eonlentsof this consignment ara fully and accurately TOTALS 10,1 <br /> described above by the proper shipping name,and are Classified.Packaged,marked and Iabelledlptacarded,and .IfZ <br /> are In all respects in proper ndition for traannsport ewooTdinng to appkable international and national goys at regulations:' )n <br /> I - Name �'C c'f SignatureDate 1D'�• <br /> 0.TRANSPORTER t ADDRESS: UK Pf>Qne N: <br /> APWicOALft�9AXra, 5506 <br /> 11875 White Rack Rd <br /> STCRICYCLE X Thio is a Through Shipment <br /> TRANSPORTE • �e�ajgt Waste as deserted above, <br /> a <br /> ~ Prin a Name L49-1-10. <br /> �P Signature Delta <br /> 5.INTERMEOtATE HANDLER Z l TRANSPORTER 2 ADDRESS: pie M: - <br /> APplloable Permit Numbotti <br /> - INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> s <br /> Printrrype Name Signature nate <br /> 6.INTERMEDIATE HANDLER 31TFiANSPORrER 3 ADDRESS: Phone If: <br /> Applicable Pertrdt Nwftem: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> e PrInVT a Name <br /> yP Signature Data <br /> 7.DISCREPANCY INDICATION <br /> Transfe , containers. 7 e.43(0 cu ft to • North Salt lake UT l <br /> ❑0&DeslgnaWl Fad0ty: 88.Aftunate FeeNity: BC.Attemate Facility. � p�'l cant Facility. <br /> STERICYCLE.INC. STERICYCLE.INC. STER1C11 NQF BICYCLE,INC. <br /> 1345 Doolittle Drive.Suite C 4135 W.Swift Avenue 90 North 1100 West AS Stm Dr <br /> San Leandro.CA 84577 Fresno.CA 93722 North Saul lake.UT Yuba City,CA 05081 <br /> (510)502- 1781 f 559)275.9994 (801)036- 1555 $-W85 <br /> TS3l.T5E(7MG TSIOST 22 chms V!t>ainecal3ot► 1 t5 <br /> j TREATMEW FACILITY:I certify that 1 have been authorized by the applicable s Ie age acre realed medica wastes d that 1 have <br /> received the above indica w S in accordance with the requirement in Zh ation. <br /> PHWFUjpe Name Signature Date <br /> it <br /> nn�n.ua� <br />