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Hx Date/Time MAY-25-2011 (WED) 15: 35 {' <br /> 05/25/2011 FCBD 15: 50 FAX P. 024 <br /> 0024/049 <br /> s htle' IN CASE OF EMERGENCY Cowmcr CHEMTREC i40042403po sTANOARD MMIFEST p0t-lo4W8Tp <br /> ►mo o rte.ue+d aw► Route #: 413 -g Cu3 tomo r No.21132 <br /> MDRC009K52 <br /> 1.Generator's Name,Address andTelepflone Ntrmber <br /> ATTR: Ge•�le MoWes <br /> BIO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> 209 334-3411 11/5/2010 <br /> Cummm NWAS" — L1BrENA70rt'S REGt1rr11ATi0N 1t <br /> 2A.DESCRWnONOFWASIE 2N. CONTAINERTYPIR 2C. NO.OF 2D. VOLUME <br /> UN3291 Regalated Medica!Masts,ft CONTAINERS <br /> 6.2,PGt� OQT-Sin 13 3at65 - SloSgstcros Shnzps Tra»s Cast (59 cu ft) <br /> UN3291•Regulated Medical Waste,a.o 5, Cu <br /> 6.21 PGII IWE - Bio3Vst•cass Transport Box (4.3 cu it) <br /> UN3291,Reputed Modica!Waste,11.5.0., Cu <br /> } 6.2,PGII <br /> UN3291,ReguMcd Medica!Waste,nos,. <br /> C 6.2,PGI! <br /> U UN3291Regulated N WW1 Waste,n,o.s., <br /> 9 t£2,PH <br /> } <br /> 6.2.PQII UN3291,Regulated Medigl Waste,nmos,, Cu <br /> • <br /> B329f Regulated Free WasWaste,11,0.0, <br /> .P011 <br /> UN3291,Regulated Medical Waste,nos,. <br /> Cu <br /> PGii <br /> Cu <br /> RSBI <br /> 3.Generator's cartnloatfon:'I hereby declare that the contents of this consignment are fN1y and accurately TOTALS ► <br /> described atNW9 by the proper shipping risme,and we etas OW,Packaged marked and lahelEedrplarrdad,end 17 <br /> are in all respects In proper Condition for transport according to applicable international and national govern ental rel7ulatlons 7 <br /> •F'rinleWTyped Name Store <br /> 4.TRANSPORTER 1 ADDRESS <br /> 11075 White Rock Reg Phone fte Per Numgas r 5505 <br /> AppticaSle Permit Numbers: <br /> Sri'DRICYCL£ This is s Through Shipment <br /> TRANSP©F3TECAIh a o8�1e'&l��l waste as dascnbed <br /> Prlru/Type Nerveg?j Signature Data .V <br /> S.INTERMEDIATE HANDIER 2 IT R 2 ADDRESS: pie p; <br /> u <br /> Applicable Permit Numbers: <br /> - INTERMEDIATE HANDLER/TRANSPORTER CER71FICATION:Rete t of medical titre <br /> � tP Ste a9 deSCitbed above. <br /> PrhtVType Name Signature Data <br /> SSu 6.INTERMEDIATE HANDLER 3 r TRANSPORTER 3 ADDRESS: Pltoeta!r: <br /> Appllcabfe Permit Worbari- <br /> - INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of meoical waste as deaAbad above. <br /> 6 Pdrit(Type Name Signature <br /> 7.DISCREPANCY INDICATION p' �� <br /> Transferred I&containers, 0 cu � ► � lake, LIT <br /> Q$A.Oesrgaated Facilt[y: V.Alternate Fedgty: 11C,A@eroate F&W)ty; aD Akemate Faculty; <br /> �YEINC. RICYCITE ifiiC. S E?{CYCLJ.V STERICYCLE INC. <br /> l �.gate G5 W.S�vtft A nue 9 Notch 1100 Vlrest !612 Starr i3r <br /> (510)562 1781 a��++577 5912 CA 993722 Alott)t Salt T y Yuba C• ,CA 85881 <br /> (5591275-OB84 (SOtj 938�- 530 7 <br /> TS3 .Y5f4ST25 '�SNJST2t classy NWecaftri pevcra P B,P-�5 0585 <br /> TREATMENT FACILITY: COO&that t have been authorized by the appli state to accept untreated medical wast and t t I have <br /> received the above to tB5 In acooAArdanca with the realufr utltned tion, 1! <br /> PdnNrypeNacos VSignature L Date / /7 <br /> o/ ) <br />