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Rx Date/Time MAY-25-2011 (WED) 15A5 P. 027 <br /> 05/25/2011 WED 15: 51 PAX ®027/049 <br /> i0 5r*es.ara++aw.e.s�sq IN CASE OF EMERGENCY CONTACT:CHEM-17REC 1.600.424.93Dt1 t3TAPtDARD IaANtFEST Ddl•itWe•STO <br /> Route #: 913 Customer No.21132 MDRC009B4P <br /> 1.generator's Name,Address and Telephone Number <br /> BIOILODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> (209) 334-"3411 10/812010 <br /> CUSTOWA Nuuar" 7-002 OENERATpA V REGWmTM%0 <br /> 2A.DESCRIPTION OF WASTE 26. CONTAINER TYPE 2C. Na OF 20. VOLUME <br /> uNs291,Regulated Atli aA RR65 •- U09ystoms Chaxps Trans Cart (59 cox it! CONTAINERS 7s <br /> 82 PGp D <br /> UN32% Regubted Mocgcal wasta,R.p.g„ V q G <br /> 6.2,11311 KRB$ — Bio8 ztemn TEann art Box (4.2 au ft? <br /> uZtw9l1I ReQolated Medleal Waste.n.o.s., C1 <br /> UN3291.RtPbtad Medical waste.nos, Cr <br /> U UN32gI Rtgulatad futedkal Waste,na.s. A <br /> 6.2,P61i <br /> 9 UM291 Regulated Mttdkal waw,U.S., Cm <br /> 6.2,PGIM <br /> UN3291 Repulaled Medial waste.n.0.&, Ce <br /> 6.2,P61i <br /> UN3291 flWaled Medical Waste, <br /> 6.2,Pali <br /> RBBI . <br /> 3.Generator's Cerilftation:ry hereby declare that Ihe'eontenta o1 Ihis consignment are fwy and amratety TOTALS ► <br /> described above by the proper s4ping name,and are c4milled packaged,marked and 1abe6exVplacarded,and ct <br /> are In <br /> all respects In proper co 'Ian for Iransport aaDrding to applicable international and national govern tal re talions." <br /> IPrlrtt Nam 42 adw--&�Signature Data ' `/O <br /> Ir 4.TRANSPORTER 1 ADORES S Phone <br /> 916? 908 y 5506 <br /> 11B78 White Rock Rd I' per'nu m' e$ <br /> IL 57CRICYCLE 'f'fria is a 'Through Shipment <br /> TRANSPORTERS .*i Q?M cRA&M waste as described above. r� 1 <br /> P,iNtfypaNama Signalure Date L40'(rf'( <br /> 6.INTERMEDIATE MM40.ER 21 TRANSPORTER 2 A DRESS: VPhone N: <br /> Y <br /> Applicable Permit Numbers: <br /> INTERMEDIATE=HANDLER/TRANSPORTER CERTIFICATION:Aece t <br /> ►p of mad!rat w aste,as described stroma. <br /> ra <br /> PdnUType Name Signature D <br /> u S.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone Ef: <br /> < Applicable Permit Numbers: <br /> INTERMEDIATE� HANDLER/TRANSPORTER CERTIFICATION:Recei t o1 medical w= p este as descMhed above. <br /> z Prtnoype Name <br /> Sigrretur8 pate <br /> ?.DISCREPANCY INDICATION (� <br /> Transferred �10 containers, - T Cu It to : <br /> eA Ceeigmumtsd fltelaly: 0-An nitB Feciltty: 8C.Atm molt FAWlip I B g <br /> STERICYCLE.INC. STERICYCLE.INC. STERICYCLE INC. RICYCL E.INC. <br /> 13450001iltle Drive.Suite C 4135 W.Svw tAvenue 90 North I IGOV;est VT 2 202 Starr Or <br /> San Leandro.CA 94577 Fresno.CA 93722 North Sale Lake,UT 84054 Yuba City,CA 05901 <br /> (510)502- 1791 (559)275-0094 (8011930-1555 )765-0585 <br /> TW.TS(O ST25 TSIO ST 22 Gass V ttvanatad <br /> TREATMENT FACILITY:i certify that I have been authorized by the applicable ate a D accept untreated mel ,cal wastes and t t I have <br /> received the abon in ed es in accordance with the requireme ed In-t zation. , <br /> Print/Type Name 22 eSR Signaivre Daie <br /> 00343 <br /> AlfRIl1A1 A� <br />