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KX Uate/Time MAY-25-2011 (WED) 15: 35 <br /> 05/25/2011 WED 15:48 FAX P. 019 <br /> ®019/049 <br /> 4r+0 Stertrydg'P. ,.�Cta $'1i:yff '9 CONTACT C}EM't1iECI�po <br /> ' & W4/emtbk' 7tR1]bG 4lS CLS mRS q. ISTWt-Ifl-0bSTD <br /> 1.Generator's Name,Address and Telephone Number Ill lfl i IlEEI!1ilfli tl 1 f 111 f it lilllll i illi li lift ! <br /> "�' '�`' '=1'.`t<a.t =''4VJLJ fEf 1iDlEfllllfi111 ff 1 i EII f i#til ill!fl !I Illi f 1# <br /> A+ ���, v t#I111EfffE1111l111n1fEllfi#Ilf�filfil���ti�IE#liill� <br /> BIO/LORI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI . CA 95240 <br /> 2a9 334-343.1 12/24/2010 <br /> tarsrormn NuraFngnq of _ <br /> Garren,uta RreTxa t <br /> 2A.DESC1tI—no OF WASTE ev. COWAINen TYPE <br /> UNMI R 20.WO.OF 2t> VOLUME <br /> 6.2,PGI# egtAated Medial Wage,n.o a. COFIr <br /> DOT-SP 1 XR63 — BiaSpttems Sharps; Trans Cart (5g ca f't) <br /> 6 fPNGl Re9MOd Medial Waste,n.os., r qr <br /> 6,2,PGl# XRBX — Bio3yoteme TZAnsport Box (4.3 t:u ft) i <br /> QX 6UNG14 Regulated Medical VYaste,ILa.s., Ou <br /> Q UN3291 Repittated Medittl Taste,n&L, Cu <br /> jr 6.2,PGti <br /> W UN I" Requ>awiwedlcallYaste,n.o�. Cu <br /> W 6.2,PBii <br /> UN3201RMulated Medley waste,n o a., Cu <br /> 6.2,PGti <br /> U14291.Regulued medical Wasta.041 Cu <br /> 6.2,poll <br /> UNMI.ftutated K10111 t Waste,a.o•s.. C,u <br /> $.2,PGII <br /> Car <br /> RXBI 22 1D <br /> C <br /> 9.liisnarator's CettiRcatlon:9 hereby declare that the <br /> 0OMen1e o1 this consignment ase tufty and acimmiely, TOTAE.$ E1 <br /> de dabove Of the proper shipping name,and are classified.packaged,marked and labellsprpWxarded.and C <br /> am In all <br /> eu <br /> )} spans in proper condition for trapmsport according to appllcahle intematloned and national governmental negularkms' <br /> SA- <br /> ' IP Name ` Signature Date <br /> 4.TRANsF oKi ER 1 ADDRESS. <br /> 0 Appli0aWe9t3errtdt�Twtr6ers: 55 Q s <br /> 0 11.875 t1lk;ti4 12oC>` Rd <br /> to y 57CRICYCLE This i3 a ThSrough Shipment <br /> El <br /> L TRANSPO Tile as described above. <br /> ftrd]ype Name 6rgnature Data iZ IF <br /> ` <br /> 5.INTERMEDIATE HAWLER 2/TRANSPUATER 2 ADDRESS: i+: <br /> iPhone <br /> i Appiicabls Permit Numbere: <br /> , <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medkal waste as described above. <br /> i - <br /> , <br /> Printrrype Nance Signature Date <br /> W 6,INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: <br /> Phone N: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrinVType Name Signature <br /> 7.DISCREPANCY tNDICATtON <br /> Transfe d containers, •d�ou Pbk 'I�farth alt lake, UT <br /> ❑tiA Dasipnaled Faclltty: Atrernota i=acltily: BC.Attemate Faenity: �t1 8D.Alrarnam facility: <br /> }Aht o t <br /> STERtCYCtE.IiVC. STf=RiG1rCLE.1NG. STRICYCLE,IIVC. STERIGYCIE,INC, <br /> : 1345 Doolittle Drive.Stine C 4135 W.Swift Avenue 90 North 11 st 1812 Starr Or <br /> San Leandr1o.CA 94577 Fresno,GA 037'22 <br /> �orth <br /> Salt Yuba C ,CA 95$81 <br /> f 5101552- 1781 5581775-0999 <br /> 10f 1938. 55�a j53Q17v -fl585 <br /> T531.TSlOST26 TSi4ST 22 lass V Inanerai ion Pamrit#9 P.6,PA tb <br /> TREATMENT FACIL •I Certify that I have been authorized by the applicable state ag to accept untreated medical wast s and that 1 have <br /> recehred the Scat stes in accordance with the requifement ed in thoftation. <br /> PrinVT�pe Signature Dale <br /> J <br />