Laserfiche WebLink
Hx Date/Time MAY-25-2011 (WED) 15: 35 <br /> 05/25/2011 WED 15[ 50 FAX P. U23 i <br /> 2023/049 <br /> �!s 'St:ericyde• IN 40ASEf F E GE CY CONTp�T.CNEMTRfC sFaNpArtD MJ11dIFEST aot.ro oe sTo <br /> • r .�.a.e,,,.,� Route : Cu�toa,er � JIPRCn1;1gY70 <br /> TBIO/LODI <br /> enerator's Name,Address and Telephone Number i <br /> ATTN: Ga�,�l.e Moes <br /> MEMORIAL, HOSPITAL <br /> 75 SOUTH FAIRMONT DRIVE <br /> ODI. CA 95240 <br /> (209) 334-3411 11/12/20 .0 <br /> CusmreR Nuveen 60890 7 7-002 GMEPLAMR'S REMMnaH i <br /> 2A.DESCRtPT1ON OF WASTE se. C04FA- FI TYPE <br /> UtI32gT Regtdated M zc 0.OF <br /> 20. vOLUAtE <br /> 6.7.PG>I I a 1165 - BxgSgstc,rar St►arps ?rams Cart (59 cu ft) CONTAINERS <br /> tIN3291.RepulatedMstfk814Vaste.ao.s.. KRB$ <br /> 6.2.PGII _ BioSVstema Transport; Box (4.3 au tt) CG <br /> C IJN I Regotated Medical Waste.n v s., Q <br /> 3 6.2.psi <br /> G $23 01 Repulattd ttttdiW Waste,ao.s,. G <br /> J UN3291.Reputated Medical waste.a.o,&, <br /> N 5.2,PGII <br /> g 8 nth Regubted Medical te.ILO.S.. G <br /> IJN3291 Regulated Medical Waste.no.s,. <br /> 6.2,pGli <br /> uN3291 Repugted Nledigt teraste,4.0.4., <br /> 6.2.PGII <br /> k�BI r <br /> S.4anerator%Certttleatton:`f hereby dedare that to contents of this natant are <br /> desalbod strove by the proper shipping name,and are classified,padre =1 =1 <br /> rg Viand accurately TOTALS ► <br /> are in all reapecis ht proper itiioon br transport according Io apptical a international end rret,�tacarded,and f�c+ cr <br /> I govor tai regatations; <br /> Prin ped Name SI na <br /> 4.TRANSPORTER 1 ADDRESS: Date <br /> Plwnel6) 995 — 5506 <br /> 11875 white Rock RdApptirabte Permit Numbers: <br /> © <br /> STERICYCLE This in a 'Mrough Shipment <br /> TRANSPORTEft%"�If 0 57waste as described above. , <br /> PdnVfype Nam,—." signature (/ <br /> S.INTERMEDIATE HANDLER 2Ll �1TFUINSPORTER 2 ADDRESS; Oete <br /> Phone N: <br /> AppFkabte ftnMt Numbers <br /> 5 INTERMEDIATE HANDLER/TRANSPORTER C <br /> ERTIf'ICATIDN:Receipt at modlcal waste as described above <br /> Pr}ntltype Name signature <br /> Gate <br /> S.INTERMEDIATE HANDLER 3[TRANSPORTER 3 ADDRESS: <br /> i Plmna N: <br /> Applicabta permit Numbers: <br /> Or <br /> INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION:Receipt of medics[waste as described above. <br /> 9 Print/Type Name Signature <br /> T.DISCREPANCY INDICATION Transferred <br /> bats <br /> Transferrer! t: containers,agj�ou ft to : North Salt lake, UT <br /> t1A Deslgrraitgd FasUlty: 86.Afterratf F <br /> Y: BC.Alternate Fersitity: Bit.Alternate FaclAty: <br /> I i RDoa�a IAC to CUE.INC. C NC. g <br /> Samar rt�A 5?7 C rriewsnol.e, ue o 1 i SN 845341 fir .INC. <br /> f59Q)3BZ- 781 F5b9115- 05n <br /> � j95 y y j g5999 <br /> TS3t.T94ST25 ( 105b=Q585 <br /> T1�4ST 22 .,lass!lttd ' sr P�B�P-tt5 <br /> DACE ANNE ORTI ALE 0 <br /> TREATMENT FACILITY:I Certify that I have been authorized by the apPHCable state agency 10 aocvctf�n treated medical wastes and that I have <br /> recon t above �Indicated wastes In accordance With the requirement outlined In that-w9tha�i>Tu �U <br /> Sipnatrrre 2010 I�Vt�J1 Y� <br /> Date <br /> Pee do, <br />