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i <br /> Rx Date/Time MAY-25-2011 (WED) 15: 35 P. 049 <br /> 05/25/2011 WED 15: 56 FAX 12049/049 <br /> ICS70 Ster cycle' <br /> • ft—ft kWh.at&"no IN CASE OF EMERGENCY CONTACT.GH1 MTREC T-806x424 AICD 5DARD E5i S� <br /> 2ot.j046 STD <br /> Route: #: 413 -0 Curtomar No.21122 MDRG009SVx <br /> 1.Generator's flame,Address and Telephone Number <br /> ATTN: Gaye Moses <br /> BIO/LORI MEMORIAL NEST CAMPUS <br /> 800 3OUTH LOVER 3ACP MENTO ROD <br /> LODI, CA 95242 <br /> 209) 339-7668 10112/20/0 <br /> GlrltTr)MtER Nit1AeER (111 GsmRAwn s REGmTRAnorr <br /> 2A.DESCRIPTION OF WASTE 2e, COMTAINERTYPE 20. NO,OF 20. VOLUME <br /> UN3291 Regirfated Medial Waste,n,o.e. CONTAINERS <br /> 6.2,PG11 DQT•Sp t AR65 -- BloSysteRms SbAxps Trans Cart (54 cu ft) D <br /> SIZPGI�R�utaNdMedialWaste,nos., MZ - BioSystemv Trarz5vort Sax (4.3 cru ft) <br /> r UN3291 Regulated Medical Wasle,nos. G <br /> 8.2.PGI1 Cr <br /> = UN3291 Regulated Me"►4taste,n.o.a., <br /> r 6.2,PGI! <br /> U 1,114322t Regulated Medical Waste,n.o.s., <br /> C 6.2.PGII <br /> UN3291 Regulated Medical waste,n.a.e.. <br /> fit.PGI! C1 <br /> UN32MI,Regulated Medical Waste,n.os.. <br /> S.2.PGR <br /> 11N3291.Regulated Medical waste.mos., <br /> 5.2.PGII <br /> 3.Generator's Cardiketton:'I hereby dechm that the contents ut this Consignment are tufty and acmntely TOTALS ► '� $'-C 0 <br /> described above by the proper stripping name.and are clas0ed,packaged,marked and IabeIkm*laearded,and <br /> are in all respects in proper W,,Itlon for transport sowrdin td eppl€Cable international and national gcver tal regulations' <br /> XPdnted/r ed Name Stgnattr t- <br /> 4.TRAN5PORFER 1 ADDRESS: phone[a r, <br /> AppftcauT AAM N�k99r ; 5 5 4 6 <br /> 11875 White Rack Rd <br /> R $rt'ERICYCt,£ Thin to a Through Shipment <br /> TRANSPOMERAMP1 l gt14aKtgewaste asdescribed above. <br /> PrinViype Name Signature Dale <br /> 6.INTERMEDIATE HANDLER 2l TRA RTER 2 ADDRESS: R)d4"; <br /> Applicable PorrNl Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrinIf"Name Signature Date <br /> u S.INTERMMATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone N: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt oI medical waste as described above. <br /> E PrinVType Name Slgnatwe Date <br /> 7.DISCREPANCY 1NDICATipN d <br /> TransfEwred � carltalr7ers C -� ct.t ft to : North Salt lake UT <br /> 9A,Deatgrww Faeatty: 111".Atwnsts Feoatry: 5C,Alaemats Facility: 80_Anumata Faeatty: <br /> a <br /> STERICYCLE,INC. STERICYCLE.INC. STERICYCLE,INC. STERICYCLE,INC. <br /> ! 1146 nnnlirtp nava Sr lisp f: 4135 W.Svrift Avenue 90 North 1100 West 1612 Starr Or <br /> I t aanrim CA sz4+;77 Frpurn CA 03777 North Salt Lake.UT 840'54 Yuba City,CA $5891 <br /> (5101 602-1 781 (5591 275-0994 (801)938. 1555 (530)755-0585 <br /> TgRt 1"S1n1;T95 MOST 22 tassVirD P 1P-8,P-t tb <br /> P412 TREATMt:NT FACILITY:I certify that f have been authorized by the ap b eoec�'pt ntr�yea ed me�k..sr..ro�ree pr,..x,At l jtave <br /> reoelved the above indicated was�in afmordance wfth the requirement outlined In tha�horfzat+e+ `0 <br /> f� cI <br /> Prinif"Name �"L O r 2 2 2MTDate! <br />