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Rx Date/Time MAY-25-2011 (WED) 15: 35 <br /> 05/25/2011 WED 15: 49 FAX P. 021 <br /> Q021/049 <br /> 5tericyde' N CASE O EMERGENCY CONTACT:CHEMMEC 1,80042 <br /> h*K r.gy.Nk%ftQW Route: : 41,3 `� Cuy't>�meL NO-21132 STANOAApMIWiFESTcot-1og8.STy <br /> Mi?RCsI{1A22Z <br /> 1.Generator's Name,Address and Telephone Number <br /> iRa 111• VUY;�. i/VJLy <br /> $IO/LORI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> (209) 334-34fl i21312020 <br /> Cuttror¢A t lUuaEa.. r GENERATown RewsrRA IoN r <br /> 2A.DESCRIPTION OF WASTE 25, CONTAINER TYPE 2C. NO.OF 2Q <br /> Uh13291,Regubted M I yyyyas .n CONTAINERS OF VOLUME <br /> 8.2,PGIi ovOT SP 1 MR55 — BiaSpstems S"s Tuns Cert (39 cu ft) <br /> UN3291,ReguWed Medical Waste•n.e.s., <br /> C <br /> b.2,PGR Bio5V%tern= Transport Bax (4.3 Cu ft) <br /> 6�II Regulated Medical Waste,n.os., C <br /> x UN3291,Regotated Modital Waste. <br /> C 62,PGR <br /> U LIK-01.Reguitted Med WaWaste,n.e s.. C <br /> r 82,PGIt <br /> It <br /> N3291 Regulated Medical waste,a.os., C <br /> ,2,P l <br /> UN328i,Regulated Medical Waste,no.&, C <br /> 6.2.PGII <br /> UN3291 Reguhttd Medical Waste.n,o.s.. C <br /> 6.2,PGIi <br /> C <br /> R.BBI C3 133 .`r Z <br /> 3.02neretOle CertificaWn:'I hereby declare that the Contents o1 this consignment are lofty and accurately TOTALS III, 3 �S --7O <br /> described above by the proper Shipping name,and are da=111 ,patscaped,marked and <br /> tabeilaftlecardad,and <br /> are In all respects in'"" cor <br /> PAIJOA for transport according 10 applicable Iniernatlonal and national <br /> gore air Mations' <br /> PrinledrtyAed Na tore - Date l -3•r <br /> 4.TRANSPORTER f ADDRESS: Phone N. <br /> 11�� yy��g5 <br /> °C 11875 White Rcer ted <br /> Appl)cL9Pani>it(,Turrabers: 5505 <br /> Thin im a Th=ou me <br /> h shipment <br /> STERICYCLE <br /> Tars 5 P <br /> Q TI:tAN$RO f3AEl ante as dutxibed abore. . 2 )1 <br /> Pr1nt/Fype Name Sigrratwe Date,r 3•(O <br /> A S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADMESS: Phoria r: <br /> t Applicatba Permit Nwnbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFlC <br /> ATION:Receipt of medical waste as described above, <br /> Printrtype Name signature Date <br /> B.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS., Phone a': <br /> ApplIcable Permit Numbers: <br /> 3 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medtcel waste as described above. <br /> —s PrinVIl W Name 5lgnature Date <br /> 7.DISCREPANCY INDICATION Q <br /> Transferred 3 1 containers, 1. 1.1 C°�ia ft to ; North Salt lake, UT <br /> O ex Design qed FaeRlsy- 08.Arawnste Foo ley; 8C.ARamate FaWft 8D.Altafmis Pao mr. <br /> STERICYCLE.INC. STERICYCLE.INC. STERICYCLE,INC. STERI CYCLE.INC. <br /> 1345 Daofitsle Orme.Suit?C 4135 W.Swift Avenue 90 North 1100 West 1612 Starr Dr <br /> San Leandro-CA 9457'7 Fresno.CA 93722 Nor&,Salt Lake,UT 84054 Yuba C' ,CA 96991 <br /> (5101582- 1781 (8011935- 1555 <br /> Tj (5591275-0994 -(53017 5-10585 <br /> Tsrq;T 22 t P <br /> ORTi DAA Z <br /> TREATMENT FACILI Y:I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> received the above Indicated wastes in accordance with the retiuirement outlined In that authoriraddon, <br /> Print/Type Npme�+ 0 J2010 Signature nPr 17 2010 <br /> Dare <br />