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<br /> - MEDICAL WASTE TRACKING FOAM NUMBER
<br /> •�� StericyCle' IN CASERF EMERGENCY CONTACT:CHEMTREC�t-800.424- 3 STANDARD MANIFEST D0140-06-STO
<br /> !' ..s. tea• ,A Route #: X313 -e Cu3tomer Na-211�3� M1)RC009TCJ
<br /> 1,Generator's Name,Address and Telephone Number III 118811181191181111 I I loll Ila11A1aiIIII III Ilia Bill all
<br /> �I &Al. uuti�a �;��`u 111111011181110110111111911
<br /> lllln0lllitl0IB ill1laiil0iliDfiMllp�11111 ®1BDa«
<br /> BIO/LORI MEMORIAL HOSPITAL
<br /> 9'15 SOUTH FAI RMONT DRIVE
<br /> LODI. CA 95240
<br /> (209) 334-3411 10/15/2010
<br /> CusTomER Nu:aaER — GENERATOR'S REGISTRATON S
<br /> 2A.DESCRIPTION OF WASTE 213. CONTAINERTYPE 2C. NO.OF 20. VOLUME
<br /> UN3291,Regulated Medical Waste os. CONTAINERS'
<br /> 6.2.PG11 Df7T-SP 1�5s5 IrDt65 - Si.Systems Sharps
<br /> ,harps Trac.^. Cart (59 cu ft)
<br /> Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGI1 KRSS - Sio3g5xeme Tran=port Sax (4-3 cu ft) Cu Ft.
<br /> UN3291,Regulated Medical Waste,mo.s.,
<br /> 0 6.2.PGR Cu Ft.
<br /> QUN3291,Regutaled Medical Waste,n.o.s.,
<br /> 6.2,PGII Cu Ft.
<br /> W UN3291,Regulated Medical Waste,n,o.s.,
<br /> IZ 6.2,PGII
<br /> Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o,s.,
<br /> 6.2,PGII
<br /> Cu FI.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII Cu Ft.
<br /> UN3291,Regulated Medical Wastc n.o.s.,
<br /> 62,PGII Cu R.
<br /> RXBI Ca Fl,
<br /> 3.Generator a Certliieatlon:-1 hereby declare that the contents of this consignment are fully and accurately TOTALS 0- Cu Ft
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and
<br /> are in all respects in proper co diWn lot transport according to applicable international and national governme tat re uladons." 'y
<br /> I Printed/ryped Name -Signaturer Date �1�✓
<br /> 4.TRANSPOATER 5 ADDRESS: Phone§lE)
<br /> M 985 - 55uE
<br /> W Applicable Permit Numbers:
<br /> 11875 White Rock Rd
<br /> Q O Thim i3 a Through Shipment
<br /> N
<br /> Q a TRANS PORTE LISA 03�t d3 F96de4l waste as described above.
<br /> o:
<br /> ~ Print/Type Name Signature Date
<br /> S.INTERMEDIATE HANDLER 2/T $PORTER 2 ADDRESS: Phone n:
<br /> Applicable Permit Numbers:
<br /> NJ INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrinVType Name Signature Date
<br /> ,,yr 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 4:
<br /> ox Applicable Permit Numbers:
<br /> rINTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> a
<br /> PrinVtype Name Signature Data
<br /> 7.DISCREPANCY INDICATION
<br /> I - Transfpirfed containers, cu ft to : North Salt Lake, IIT
<br /> 8A.Designated Facility: 4,
<br /> Alternate Facility: 8C,Alternate Faculty: LJ 813,Alternate Facility:
<br /> I
<br /> sTERICYCLE.INC. STERICYCLE.INC. STERICYCLE,INC. STERICYCLE.INC.
<br /> 1345 Doolittle Drive.Suite C 4136 W.Sw*Avenue 90 North i IGO West 1812 Starr Dr
<br /> San Leandro.CA 84577 Fresno.CA 93322 North Salt Lake,UT 64054 Yuba C' .CA 95981
<br /> W
<br /> (5-1016132-081 (5581 275-0994 ($011938- 1555 (530)755-0585
<br /> 2 11 TS31.TS(OST25 TS(OST 22 Classy tneinermtiGn Pem iw 91 P-6"P-415
<br /> eL TREATMENT FACILITY: 1 certify that I have been authorized by the applicable state agenc tqr�'
<br /> crept untreated medical waste and that I have
<br /> received the above7indi wa in accordance with the requirementoutlin that ation. r� ��
<br /> Print/Type Name Signature Date
<br /> 00-287
<br /> ORIGIIiiAL
<br /> FP1Re.M 6064Id 13414
<br />
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