Laserfiche WebLink
ttx hate/Time MAY-Z5-ZQ11 (WED) 15: 35 P 098 *' <br /> 05/25/2011 WED 15: 56 FAX 1@048/049 � <br /> IC-070 Stericyda' .CASE OF EMEMENCY CowACr CH REC 1-000424-M STMT � <br /> �rn�E57 ao:•sam sro <br /> • .. ...�,� Route #: 413 -1 Customer N0.21132 MDRCOOA4ER <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN: Gayle Mose, <br /> ILIO/LODI MEMORIAL [BEST CAMPUS <br /> 800 SOUTH LOVER SACRAMENTO ROD <br /> LODI, CA 95242 <br /> (209) 3.39-7668 12/17/2010 <br /> cus"MMNuMM 6089077-003 Gomm""R"aamilm <br /> M DESC.fi1PTION OF WASTE 2B. COMTAINEfi WK ?C. Na OF <br /> 2D. voLU11tE <br /> MGUMA XR65 - Rio9ystew Sbarps hand: Cart (59.cu ft) CONTAINt7tS <br /> UNM Regulated M"co Waste,n.o.e. a+ <br /> 6.2,Pcii KR8$ — $io3vatems Tramport Box (4.2 cu ft) <br /> tflM3291 Regulated MtI Waste,n.os., <br /> p <br /> 16.2,PGI1 <br /> M 6.2,PGii Requlared Medi�r wase,re,e.s„ , <br /> WUlt3291 Regslattd Medical Waste,n.tss., <br /> tZ 6.2,Pati <br /> UN328tReoutated Medica(Waste,us., Cu <br /> 6x,PBIi <br /> UNMI.Regulated Medical Waste,_0.21 PGII <br /> Ce <br /> UNW1.Re dwd Medlcat Wastd.n.t).s„ Cu <br /> 6.2.POO <br /> Cu <br /> RXBI Z <br /> 3.Genen"es COM90111110n:-I hereby declare Mthe carltenle of tMs oonslgnment are funy and accurately TOTALS r .,7 G� o► <br /> described above by the prapet shipping name.and are dasstlied,packaged,rrte td and labelledlpteCarded.and <br /> are in ail respects In proper ition far transport to pplk�Ybi0 intemational and national govern IaI regut tions' <br /> 1 X PdnWdffVW Name Signature Date 1247-/0 <br /> 4,TRANSNORTER 1 RtHIRESS: i=_ <br /> 6 '-916) gas - 5506 <br /> m <br /> 11875 Whitt Rock Rd Applicable Permit Numbers: <br /> STERICYCLE K Thin is a Through 3hipmienr. <br /> r z TRANSPORTER'eER'ITFI(FAVf ? GAW?+vasta as das two aware. A "� <br /> Pr[nt/Mype Name Alfa Signature Date f�"�I <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: pine M. <br /> i <br /> APptkablg Parmll Numbera: <br /> INTERMEDIATE HANDLER ITRANSPORT'ER CERTIFICATION:Receit of medical waste as described above, <br /> Print%"Name Signature Data <br /> i <br /> G.INTERMEDIATE HANDIER 3/TRANSPORTER 3 ADDRESS, :'bona e; <br /> gAPPnCable Permit Numbors: <br /> INTERMEDIATE HANDLER/TRANSPORTER C'EM IFICATION:fiacelpf of inedkal waste as described above. <br /> `• Pdanype Name Signature Date <br /> 7.DISCREPANCY INDICATEON <br /> Transf rred __L containers, 9" ,01 cu It to : North Salt lake, UT <br /> ❑ea Oeshlnated Fsently: 8a.Atternats fecl>>ty 6C.Agamete Fadiity: W.All num Fadllty: <br /> RICY INC. G ING. Cy <br /> ,I�1C. <br /> i � Daal e ite G NMI rtt,e SuMaNWITI$UCOI <br /> �� an an <br /> 1T001F&'i5Mh, "'f-84054 _ <br /> f 5101 582-1781 (559)275-0984 (fit)938- t 55§ (530)755.0'585 <br /> T1s3l.T�ilaST25 t �^oLrJST 22 ril.�tticistet P4 <br /> 3 DALE AN N Ezklz <br /> l TREATMENT FACI t:e ' that I have been authorized by that, icabi stats a @ to accept untreated medical wastR¢and Fi..•IF U. <br /> received the Icatasles Irt accordance with the requiram } ed fn f atsr� � �� <br /> �j i 1 <br /> Prinv"Name_ `Slgnatw Date r <br /> w r•.w•..a• ...n.aa....rnr•pas .r n_ <br />