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Rx Date/Time MAY-25-2011 (WED) 15: 35 <br /> 05/25/2011 WED 15: 49 FAX P. 020 <br /> 12020/049 <br /> 4r47* steriryde &@ COI+rr ss2113s tsr obt•tooe sm <br /> • r.r.�.a►wrwir.wrxt �r � .,._ MPRs.. rt '` <br /> 1.Generator's Nance Address end Tele hone Number t r r } <br /> tt�m>,r. G,et. t 1.1od a � � � 4 �o>,�I;tile f1 ��� fE 111 E <br /> rib i i�. Vs�Y�4 /!V J¢�r '�� � �IJ'�IIf � ' � �! � � <br /> BIOILODI MEMORIAL, HOSPITAL fF <br /> 975 SOUTH FAIPJ40NT DRIVE <br /> LODI. CA 95290 <br /> (209). 334-34 11 12(1712010 <br /> CI>Ss rest NwtatTt <br /> 6089 0 77-002 GOrtmTon•a ftorsr Tmpr It <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINERTYPE <br /> 2C.NO.OF 2Q VOLUME <br /> 6.2, t,need ML4ft Ross - B.ioS sta= sCO ERS g <br /> B.2,PGI! p hasp. Trans1Yans Ca�tt (59 cu ft) eG•-„ <br /> UNMI Anulaw Meow waste,0.04, ` Cu <br /> 6.2,PGI( 1;T�8 - Siosv=tent: Tranatsort Box (4.3 cu ft) <br /> p6�Pt'�F A��d Medical Wait n.o.s, Cu <br /> S PGl3 ReQWated Macara!waste,n.o.a, <br /> Cu <br /> CC <br /> 141 MAI Rsgu W medw wule.rLo So Cu <br /> 8.2,PGtI <br /> UIYU91ReprLated Menet wade,a.0.s., <br /> Cu <br /> 6.2,PGlI <br /> 8.2.MI Raped Msdw waste,ao.s., Cu <br /> UU2U�i1 Regetated Medhal waste.ao.s., <br /> li>tBi CU <br /> 3.Generators CertlRcataon.-I hereby dedam that the eonlents Of ft c ormlgnrneni are July are►eaxlraley TOTALS �Q <br /> CU <br /> described above by the proper Stttpping name.and are dasftcl,Padsaped,marked and Cu <br /> era In an respects in proper Itiot for transport aeoorti ft t apftbts Intematfonal and nates lonnaai� a <br /> govern real Taticrts <br /> PSPOR TyR i Nam Slgnatu Date LZ -17-le <br /> 4.TRANSPORTER 1 ADDRESS: <br /> P. I <br /> Plwe1916) 985 - $506 <br /> 0 11675 White Rack Rd ApplioaW Permft Numbers: <br /> E Co 3`PERICYCI.� X This is a Through laiptnetat <br /> i¢ TRANSPORTEWCERI4CILIA't>t0 A pr a as described abum <br /> PrtnYfT jn Name Slgneture f Date I -17--lo <br /> 6.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone*. <br /> Applicable Permit(lumbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:R <br /> (` eCefpl OI medical waste as described above. <br /> Pdnveype Name SfMature tate <br /> B.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS. Phvna ie: <br /> ig <br /> r Applicable Permit Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. �[ <br /> PAWType Name SIgmture <br /> T.DISCREPANCY INDICATION p <br /> Transle ed 1�containers, W.10brf <br /> cu It to : Noo P, �e, UT <br /> Q 8A.Dnlwwm 1`801111y: B.AkamM Facility 8C.Aeema tornata Faclltty: <br /> STERICYCLE,INC. STERrCYCLE.INC. STERICYCLE,INC.n�C' YCLE.INC. <br /> 4 1340 Doolittle 0&e.Suite C 4136 W.SWk Avenue 80 North 1400 West Carr Dr <br /> San Leandro.CA 94577 Fresno.CA 03722 NoNi Salt Lake.UTanY G' CA 85891 <br /> 1(31 582- 1181 (5581275-0984 80 i!838-1555 '.I' (530175 -03$5 <br /> TS31.TSt4ST25 TS(OST 22 Class!Indneradan 8 p-8,P-115 <br /> P11 TREATMENT FAC /hat I have been authorized by the Wilcab State to accept untreated medical wast and the I have <br /> _ received the Q icat YA t� acc la a with the requir fined orization 1 <br /> Priv rWe Rama �,/ <br /> 002833 <br /> };;pp��yy rr�� tiignafure 'Data <br />