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MEDICAL WASTE TRACKING FORM NUMBER <br /> Stericycle' F7otzteE :EfI�f"-NSEFICYCONTA�TCHEMTREC6oD, 2 (1 M�R�$j(+AIA�gp�d9frlFEsrocl•loo�5ro <br /> �F 9 1i3tvmer o. - ------- <br /> 1 <br /> -- -1. Generator's Name,Address and Telephone Number 111 111111111111111 it I!Ill I II11111II 1 I lit 11111111 <br /> 'Aq'rPAT. ro••i ���� IllIllllllllfl1111IfI111kIIIN111111111i[I11111111I <br /> P11 "' <br /> • 4"V 1` „""`" 111 11111111111111111 l l 111 l llllll1111111;111111111111 <br /> BIOILODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> f LaDI. CA 95240 . <br /> (209) 334-3411 11/26./2010 <br /> i <br /> i 6089077-002 <br /> CU57r1YER NUYBF3i GENERATOR'S REGISTRATIaN tf <br /> 2A.DESCRIPTION OF WASTE 2g• CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> UN3291,Regulated Med �hr fe CONT ERS <br /> 6.2.PGII ORT- N' n65 - 3iosgstems Sharps Trans Cart (59 au ft) <br /> Cu Ft. <br /> UN3291,Regulated Medical Waste,mo-s-, <br /> 6.2,PGH F{R$eI - BioSvstem= Tran3port Bax (4.3 au ft) Cu Ft. <br /> l= UN3291,Regulated Medical Waste,n.o.s., <br /> 0 6.2,PGII Cu FI. { <br /> Q UN3291,Regulated Medical Waste,n.o.s., <br /> It 6.2,PGII Cu Ft. <br /> UJI UN3291,Regutated Medical Waste,mos.. <br /> Z 6.2,PGH <br /> Cu Fl. <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2,PGII <br /> Cu Ft. <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 62,PGII Cu Ft. <br /> UN3291,Regulated Medical Waste,ri&s., <br /> 6.2,PGII Cu Ft. <br /> 1RSBI Cu Ft. <br /> 3.Generator's Certification:'I hereby declare that the contents of this consignment are fully and accurately TOTALS 10- ��" ( Cu FI. <br /> described above by the proper shipping name,and are Classified,packaged,marked and labelledlptacarded,and <br /> are in aA respects In proper condition for transport according to applicable international and national rnmental regulation " <br /> 1 PdntedrTyped Name )� Signatur Date <br /> i 4.TRANSPORTER 1 ADDRESS: Phone <br /> � �(9I�) 985 - SSG6 <br /> Applicable Perrnit Numbers: <br /> 11875 White Flock Rd <br /> < 9'i'ERICYCL - Thi i:; a Th£ostgh ,shipment <br /> W <br /> a q TRANSPORTE"S IFI Rec�F oPAgawaste as described above. <br /> PdntlType Name Q. Signature Date <br /> b <br /> S.INTERMEDIATE HANDLER 2ITRANSPORTER 2 ADDRESS: Phone#: <br /> Applicable Permit Numbers: <br /> p 4 <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> `nia 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone <br /> i m a r Applicable Permit Numbers: <br /> lzaa <br /> 25' INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> aLLI�� <br /> - Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transferred containers, cu ft to : North Salt lake, LIT . <br /> 8A.0e619nated FaclUty: ❑88.Alternate Facility: BC.Alternate Facility: Eo.Alternate Facility. <br /> J <br /> a / STERtCYCLE.INC. STERICYCLE.INC. STERICYCLE,INC. STERICYCLE,INC. <br /> LL 1345 Doolitite Drive.Suite C 4 t35 W.StinriEt Avenue 90 North 1100 West 16112 Starr Dr <br /> San Leandro.CA 94577 Fresno.CA 93722 North Salt Lake,lir 84054 Yuba C-tty CA 95991 <br /> LL (510)562. 1781 (559)275-0984 (801)936- 1555 (530)755-0585 <br /> Ts2iTsfo'—Z"�5 ,r,_ TWST 22 C1ass�d tr%cinecaiian Pemil 2t P-6,P-115 <br /> LU ��ut �. <br /> N C TY:I cern that i have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> F- received the above indicated wasles in accordance with the requirement outlined in that authorization. <br /> F�ntr ^ <br /> Printrrype Name 7 V nil Signature Date <br /> ORIGINAL <br /> ruttRtlastd <br />