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Rx Date/Time MAY-25-2011 (WED) 15: 35 P. 026 <br /> 05/25/2011 WED 15: 51 FAX 1@026/049 <br /> 4x47* Steri <br /> • q A CASE OF EMERGENCY CONTACT:CHEMTREC 1.Ma,42"300 STANDARD MRNWEST Com *sm <br /> Route #: 413 -8 Customer No-21132 11PRGOO-CRI4K <br /> 1.,Generator's Name,Address and Telephone Number f <br /> ATTN: Gavle Moaea III I � 116!!111 <br /> BIO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> 209 334-3411 10/22/2010 <br /> CusTorrR N1wam6QRQn _ GENEAATOWS. n 7nQ7 <br /> AEOISTMt1pN rt <br /> 2A.DESCRiFnON OF WASTE 26. CONTAINERTYPE 2C. NM OF ' 2Q VOLUME <br /> UN3291 Rewsd CONTAINERS6.2.PGI! 2i m <br /> 3865 — $ioSpx[exl� Sharps Trans Cart (59 cu Et) <br /> 03291 Repufated Medlcat Waste.n.o.s_ <br /> 6.2.PGII KRB$ — BioSvst~ems Transport Box (4.3'eu ft) <br /> C UN3291 Regulated Madlt3l Waste• <br /> 3 6.2,PGII <br /> C <br /> UN3291 tllated Medica,Waste.n.o,s.. <br /> t 62,PGI <br /> I Rep <br /> V UN3291,RepubW Medan!Waste,No.s, C <br /> P6.21 PGII <br /> UN3291.Repww Medirat Waste,rips,. C <br /> 62,P611 <br /> U2,Glli RepuM Medul Waste,n.a.a. C <br /> UN3291,Regrlbted Medical Waste,nAs.. C <br /> 62.PGII <br /> C <br /> RBBI <br /> 3.Generators Certlticallow"i hereby dodare that the contents M this consignment are fully and aecural* TOTALS <br /> described above by the Proper 61`9001119 name.and are tdaWilled,packaged,marked and labelled/ptacarded,and ' C <br /> are in all respects in proper condition Ica transport acca+ding to applicable Interriatlonal and nationalntel <br /> [ sous regulation <br /> IfPrintedl> ed Name Si to fit$ <br /> 4.TRANSPORTER 1 AOORM: <br /> =110 ftirrdl 16) <br /> Num rumhsra: 6506 <br /> 11875 White: Rock Rd <br /> -"r'1'IwRICYCL€ Q 'Phis 15 z Through Shipment <br /> TRANSPORTEPjMMFIC Rpow cowaste as described abova, <br /> T <br /> Printflype Name Signature Date 1(!• -f <br /> 6.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone 0: <br /> u <br /> Applicable Perms Nwrara: <br /> 5 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION;Rece1 <br /> pt a m ediCai waste as described above. <br /> PrfrdTI qS Name Signature <br /> Date <br /> u 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADOMS: Phone f: <br /> Appliiuble PermR Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> -x <br /> E Pnr+tfr�rPe Nwm Signature <br /> t7dtB <br /> ?.DISCREPANCY INOICATtON <br /> Trans' ed �C� rantarrsers, f lq4 <br /> cu ft to : I oFtTIZ <br /> s/L Dglgnatcd FecllttY: as.Alternate Factilty: BC.Alternate aslflt., BD.Alternate Facplbt: <br /> # ST' RCYCLE.INC. STERICY 0 01 <br /> Ct.l;.1NG. STERICYC1.l=,INC�1I'}v `S'fERiGYCLiw,WC, <br /> 1345 Doolde Drive.Suite C 4135 W.SvVift Avenue 90 North 1 i RD West 1812 Starr lir <br /> Sall Leandro.CA 94577 Fresno.CA 93722 North Salt La1ce, rry <br /> j51Q1562- 1781 (5591275-Q9I34 ($01)939. 1555�e�0 155-08fi59B1 <br /> TWi.TSIOST26 T910ST 22 Gtassv Indnn on pelma#04 6.P-116 <br /> TREATMENT FACILITY.I cer ity that I have been authorized by the 8PPAH abl to a ccept untreated rrledleat waste and that I have <br /> received the above IndlCat s In aocordance With the requirema11 1 <br /> PrinVlype Name SignatureData <br /> ID038 1 <br />