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5 <br /> ' MEDICAL WASTE TRACKING FORM NUMBER <br /> 5tericycle' CASE OF EMERGENCY CONTACT:CHEMTREC 1-800-424.93M STANDARD MANIFEST 001.10-06-STD <br /> • "°""`o"°�`'"' " Route #: 413 -2 Cuntomerf jNo.21132 <br /> MDRCOOA363 <br /> 1.Generator's Narne,Address and Telephone Number <br /> ° SIO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI, CA 95240 <br /> (209) 334-3411 12/10/2014 <br /> CummEF Numm r,(t p q 77-002 GENErtma's Rmsr unm A <br /> 2A.DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C. NO.DF 2D. VOLUME <br /> 2.FIG,Regulated Medxal f,If,V� XR55 — SioSpstews Sharps Trans Cart {59 cu f t) CONTAINER5 <br /> fi.2,PGI( uOu FF 1� <br /> UN3291,Regulated Medical Waste,n.o.s.. Cu Ft. <br /> 612,PGH RP.B3 - BioSvstems Transport Bax (4.3 cu ft;) <br /> iY U1,13291,Regulated Medical Waste,n.a.s., Cu Ft. <br /> 0 6.2.PGII <br /> !Q UN3291,Regulated Medirat Waste,n.ns.,CC Cu FI' i <br /> 6.2,PGI] <br /> W UN3291Regulated Medical Waste,1110-S.. Cu Ft. <br /> Z 6.2,PGII <br /> UN3291 Regulated Medical Waste,n.o.s., Cu Fi. <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,n.o.s., Gu FI. <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste.n.o.s.. Cu Ft <br /> 6.2,PGII <br /> Cu Ft. <br /> P—vBT <br /> Cu Ft. <br /> 3.Generator's CertRkatlon:"1 hereby declare that the contents of this consignment are fully and accurately TOTALS 0-described above by line proper shipping name,and are classified,packaged,rnarked and labellecilplecarded,and jj=Cu <br /> are in all respects in proper cond"Aion for transport according to applicable international and nallonal govern tel regulations' / <br /> XPrintecirryped Name SigneSure Date r f <br /> 4.TRANSPORTER 1 ADDRESS: Phone#; <br /> t93E} 98.5 — 55u6 <br /> y to <br /> 11875 White Rock Rd Applicable Permit Numbers: <br /> Q � - <br /> a O This is a Through 3hipmcnt <br /> 2 CL S'I'ERICYCL,C <br /> Ca tZ TRANSPORTE==ZyjMd <br /> elp of�4ied��rvaste as described above, r <br /> Prinl/TypaNameSignatureDate f O <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone p: <br /> s$ Applicable Permit Numbers: <br /> cc <br /> Y INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Pr(ntlType Name Signature Dale <br /> n,y 6.INTERmEDtATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#: <br /> Applicable Permit Numbers: <br /> a Q x INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Trans erred containers, cu ft to : North Salt lake, UT <br /> r Q EA.Designated Facility: Altemata Facility: El SC.Alternate Facluty: eD.AUrnate Fac11Ny: <br /> GYr INC. I' C INC. MIY�l� NC. 1' INC.� itsC �. Yenue 1 �5�� 3 110 ft La4Ct9 p "A ,9A1 <br /> �- (5101 562-1761 ('5591275-0994 (80 1)936- 555 `� ��� <br /> LU TS- 311.TVGST25 T129 9 P-fi,P-115 <br /> 12 )ALE ANNE ORT( <br /> WTREATMENT FACILITY:I certity that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> � received the above Indicaled wastes in accordance with the requirement outlined in that authorization. <br /> UC 12 20")_ <br /> Print/Type Name Signature Data <br /> '�•-r u3r1'�C�N I <br /> OFIIGIRIAI. rc1fZ'.1�s5rfte�d m•n. <br />