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' L MEDICAL WASTETRACKING FORM NUMBER. <br /> Ooe O StericyCIV tN CASE1 <br /> OF EMERGENCY CONTACT:CNEMTREC -800 424-J STANDAPID MANIFEST 001-10-O&M <br /> 00 rtiRoute 4. 413 '7 Customer N0.21132 MDRCOOA6VA <br /> 1:Generator's Mame,Address Number <br /> A'�TN: Gavle- <br /> le MoMoses es �]r <br /> -BIOILODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> (209) 334-3412 12/31/2010 <br /> CUSMUE t NUMBER 6089077-002 G1xtaRAToa's REGts-mnoN 0 <br /> 2A.DESCRrFrnON OF WASTE 2f3. CONTAINEATYPE 2C. No.OF 21). VOLUME <br /> UN3291Regufatedt &j , XR65 — SioSyskeas Sharps Trans Cart (59 cls ft) CO ERS [7 <br /> 6.2,PGli Qti // • a Gu Fr. <br /> Uf13291,Regulated Medical Waste,n.o.s.. S{jLB3 - Bio3ystcm3 Trsnvpost Box (4.3 cu_ft) <br /> 6.2,PGII <br /> CC UN3291,Regulated Medical Waste,no.s., . <br /> Cu R. <br /> Q 62.PGII Cu R. <br /> OR UN3291,Regulated Medical Waste,n.o.s.. <br /> 62,PGII Cu Ft. <br /> W UN3291,Regulated Medical Waste,n.os., <br /> Z 62,PGII <br /> Lu Cu FI. <br /> UN3291,Regulated Medical waste.n.o.s.. <br /> 6.2,Poll <br /> Cu FI. <br /> UN3291,Regulated Medical Waste,n.e.s.. <br /> 6.2.PGII Cu Ft. <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2,PGII <br /> Cu Fr. <br /> R$BI <br /> Cu Ft. <br /> 3.Generator's Cortifleatlon:-I hereby declare that the contents of this consignment are fully and accurately TOTALS ► Cu Fr. <br /> described above by the proper shipping name,and are classified,packaged,marked and laballed/placarded,and <br /> j are in all respects In proper condilion for transport atxord g to ffcabie international and national govern cal regutatfon"—Data <br /> '1PrintedllypedName Sin2. <br /> 4.TRANSPORTER 1 ADDRESS; PhoW3 6) 9$S — 554 <br /> W <br /> li- 11575 White Rock Rd Applicable Permit Numbers: <br /> CC CC <br /> g a 3'i'ERICYCL>~ This is m Through Shipment <br /> N uZa <br /> a Q TRANSPORTJR7 IF�Ii 1i ipPoN e I !waste as dascrib ov <br /> ~ Printrrype Name Slgnatu 9 ' <br /> Date <br /> 123 <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADORESS: Phone tt: <br /> N <br /> o Applicable Permit Numbers: <br /> 220 <br /> INTERMEDIATE HANDLER ITRANSPORTER CERTIFICATION:Recalpt of medical waste as described above. <br /> Print(Type Name Signature Date <br /> M 6.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone 0: <br /> Ejg Applicable Permit Numbers: <br /> w <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Prinl/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Transfe ed containers, cu R to : North Salt lake, UT <br /> 8A.Dealgnaled Fatllltr .Aftemnto Fadflty: ❑BC.Afternate Fatuity: 61).Ahemato Facility; <br /> CY ING. <br /> UFA$* <br /> M. RI�rG fNC. g�RIGYG INC. <br /> Waoft P bETve.Suite CAvenue orttt YVe,St 1812 Srarr Dr ' <br /> trL San Lean CA 94577 Fresno CA 93722 No h Salt Lake,UT 84054 Yuba City,CA 85991 <br /> M (510)562-1781 (558)275-0994 (801)930-1555 (530)755-0585. <br /> TS3t.TSIOST2's MOST 22 Ciassiv Indnetadnn r?etrritt!91 P-6,P-115 <br /> a <br /> Uj TREATMENT FACIL ce that I have been authorized by the applicable state age to accept untreated medical wastes and that I have <br /> N received the Kate rtes in accordance with the requiremen o d in I Orization. ( J <br /> PrintrrypeName p rA� � R Signature Date v' � <br /> (Diu-LS (a <br /> OR13INAL rtitratl�astd pan. <br />