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NX Date/Time MAY-25-2011 (WED) 15: 35 <br /> 05/25/2011 WED 15:44 FAX P- 022 <br /> 2022/049 <br /> 4-'40p"b "eStericycle• IN CASE of EMEArMy CONTACT:CHEKTnjeC t-I;Dg 424.9340 STANDARD MANIFEST Ooi.lp pg$7D ! <br /> ^mob afto*ft.&X"0W Route : r113 STANDARD <br /> No.21132 MDRC-0092 0 <br /> 1.generator's Name,Address and Telephone Number ff [[}} <br /> ATTN: Gavle Moes <br /> BIO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH EAI RMO14T DRIVE <br /> LODI . CA 95240 <br /> (209) 334-3411 1 ./19/2010 <br /> cusmEn NEIa m 6089 _ Ods litrrsTpenort r <br /> 2A.DESCRIPTION OF WASTE 28, CONTAINER TYPE <br /> 82�.P29GIiReg'datedMe e' KR65 - Biotysteum Sharps Tues Cart (S9 cu £t) COtNTOO- <br /> AINERs 2D. Y°uratE <br /> UN329t,Regulated Medical Waste.n.es„ Cr <br /> 6.2,Kill ]rCRi3g — 8iO3vdtemrs Transport Box (4.3 cu ft) <br /> C UN3291 Regulated Medreaf Waste.nos., Q i <br /> 3 6.2.Poll <br /> UN3291Regulated Medical Waste•n.o.s„ c, <br /> 6.2,PGti <br /> U !!113291 Regulated Medical waste,n,es.. <br /> 6.2.PGJI cr <br /> tJN329i.Regulated Medical wasto.n.Ds., CE <br /> 6.2,P61E <br /> U14329t,Regulated MeiiCa1 waste,n.o.s.. <br /> 6.4 PGII <br /> UN329t.Rep fated Medical Waste,n,o.s., <br /> 6.2,PGlI <br /> REBI C <br /> 3.GenBratpr's Cerlitlsatlon:'I hereby dectare that the contents of this consignment este fully and accurately TOTALS CA <br /> 3r <br /> described Above by the proper shipping name.attd are classified,packaged,marked and labetledlptacwded,ww rp Ct <br /> are in aN respects In proper 001tion for transport atxordl ID apprxable intemaponal and nationalSEgntal !kms <br /> ( T �PriMedlT Name rtatu <br /> 4,TRANSPORTER t ADDRESS; Date;d <br /> f• <br /> Phone I�j 1(>) 9a5 - 5506 <br /> 11875 White Rack ltd � Appkaw Permit Numbers; <br /> N <br /> S'PERICYC1wE <br /> This; it A Through Shipment <br /> TRANSPOtttt= <br /> ase$esdosadbedabovePrintrrype NaSignagrre Dater <br /> 5,INTERMEDIATE HANDIAR 21 TRANSPsORTER 2 ADDRESS: <br /> v Phone M <br /> g Applicable Permit Numbers: <br /> INTERMEDIATE HANDIER/TRANSPORTER CERTIFICATION: <br /> z <br /> Receipt of medical waste as described above, <br /> PdnVType Name SignaUue Dale <br /> G.INTERMEDIATE HANDLER 31TRANSPORTER 3 ADDRESS. Phone r: <br /> APAgcabla Fermis Numbers:INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of rnedw waste as described above. <br /> = PrinVtype Name - <br /> Slgnalure t7afa <br /> 7.DISCREPANCY INDICAAON y� � <br /> Transferred -'- containers, SOT•� cu ft to : North Salt lake, UT <br /> gFA 8A r3eslpnatad FasCltlr: F-1re Atbrrreta Feda:y: rC.AftenwW FocDEEy: 81).Altemete FacWtV_ <br /> CY5Kb)11nNV1iS - I�IC. i�y ��� GY INCs> heG fl? A nese �orth t%We �tarr[7r 'an E.eanA 871 t37 <br /> f5t0)562- !781 =03 276-0994 No Safi Lake fly' Fs4054 Yuba LAV,CA 95091 <br /> TS31.TIrJST2s (804)938. 4555 (53Q)75 •0585 <br /> MOST 22 w'a=3:V Lncire agaT� ('e'rro B+ <br /> ANNE ORT'{Z I�L� ANNE ORT"I <br /> TREATMENT FACILITY,I certify that I have been authorized by the applicable state agency to accept'untreated medical wastes and that I have <br /> received <br /> pthe <br /> �above indicated wastes in accordance with the requirement outlined In that authorization. <br /> PrinvTO INaktie 2 1 200 Signature npr Q 20100#4AO 9 <br /> v r � <br />