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Rx Date/Time MAY-25-2011 (WED) 15: 35 P. 025 <br /> 05/25/2011 WED 15: 50 FAX - 0025/049 <br /> 6e16 3tericycle, IN CASE OF EMERGENCY CONTACT;CHEWREC 14g)0424-OM STANDARD MANIFEST 001.10 ,STO <br /> Routes #: 413 -9 Customer No-21122 MDRC009VD4 <br /> 1.Generator's Name,Address and Telephone!Number <br /> ATTN: Gayle Manes <br /> BIO/LORI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LORI. CA 95240 <br /> (209) 3343431 11/2/2010 <br /> CuVOMER NUMBM7-002 GENERATOR•e REOre LIMON 9 <br /> 2A.DESCRIPTION OFWASTE <br /> ans. 26. CONTAINERTYPE RC.NO.OF 2D. VOLUME <br /> 6 ngl.Regulated MP�Ira� �fi5 — SioSpstems Sharps >�aaks Coact (5t# cn ft) C0IYTAINEgS <br /> LTA a <br /> 1113291,Regulated Medical Waste.no.s HUX _ Biclsv'stems Transport Box (4.3 au ft) <br /> ti.2,Pett ' <br /> Cr <br /> 612,32911 Regulated Medical waste,n.o.c. <br /> a <br /> = =91 Regulated Mediaai waste,mo s., <br /> r 6.2,PGII <br /> D UN3291,Regalaied AAs kW Waste,n.D,s., <br /> C 8.2.PGI! <br /> 3 UN3291 Regulated Medical Waste,n.o.s., <br /> 6.2,PGIi <br /> UN pill Regulated Medical waste,mos., <br /> 6.&F,PGfi Regulated Medr"Waste,nos.. <br /> RNBI <br /> 1 Generator's Certlfloatlon:I hereby declare that the oonienis of this consignment are tugy and aocuratety TOTALS 11 <br /> described above by the proper shipping name,and are dassilied,padcaged,markad and Iaballe ftlecarded,and �.•-- <br /> are in all respects In proper condition for trangwrt accnrdinq to appllw"International and nationsl govemm int Ions' <br /> .X-PrinladtTyped Nactl Si tura Date ! - •tf J <br /> 4.TRANSAORTER 1 ADDRESS: one�916} 985 — 554$ <br /> 11875 White Ronk Rd � ApplicableParmitNumbea: <br /> a'i'�RICYCLE Thits is a Through $hipmrent <br /> TRANSPORTS ;7mFL;dlwase as deribed abve. <br /> Adn�YeName � SignaturDate Date - •rIv'^J <br /> 1 <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTE:.R 2 ADDRESS: V Phone R: <br /> u <br /> • Applicable Permit Numbers, <br /> INTERMEDIATE HANDIER/TRANSPORTER CERTIFICATION:Recelpt of medical waste as described above. <br /> PrinVrype Name Signature Dale <br /> e B.INTERMEDIATE HANDLER 2!TRANSPORTER 8 ADDRESS: Phone r: <br /> Applicable Permh Numbers: <br /> ' INTERMEDIATE HANDLER/TRANSPORTER CERTIFICAT16 N:Receipt of medioaE waste as described above. <br /> PrinVrype Name Signature Date <br /> 7.DISCREPANCY INDICATION pp <br /> Transferred312 oordainer5..IA Cu ft tDl LRAwR�R�{�UTORTIZ <br /> [DOA,Desl9ndW Factilty: 8%Aftmate Faal1&y: 8C.Ansrnate Facility 8D.Alternate Facility <br /> STT-BICYCLE.INC. STERICYCLE.INC. STERiGYC#E,I AV 15 Z 10 SIERICYCLE,INC. <br /> 1345 Dodttle Drive.State C 41135W.SWR Avenue 90 North 1100 West 1612 Starr Dr <br /> San Leandro•CA 94577 Fresno.CA 93722 North Salt L a U 54 �Faolp,!, <br /> ii�tyyCA 95991 <br /> 15103 582. 1781 (559)275-0994 (801)936- 66!-€1585 <br /> TS81.T=S"T"25 TwGST 22 CtassV trvd%esti Pem�l 115 <br /> TREATMENT FACILITY:I certify that i have been authorized by the applicable state age'00nt to accept untreated medics!wast s anti hal I have <br /> received the above i ed es fn E;tCordance with the requirement a n1pr 1 1 (/�)1 <br /> PrinUType Name Signature Dale " <br />