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Rx Date/Time MAY-25-2011 (WED) 15: 35 P. 046 <br /> 05/25/2411 WED 15: 57 FAX 2046/649 <br /> •'' 5tericycie' €N CASE OF EMERGENCY CONTACT:CHEMTREC 14004244300 �D Feer Dot-io-MSTD <br /> e waa' Route 9: X113 3 Custom .�E i 133 MQRC00A8DF <br /> 1.Generator's Marne,Address and Telephone Number <br /> ATTN: Cayce 1103e3I � I <br /> BIO/LODI MEMORIAL WEST CAMPUS <br /> 800 SOUTH LONER SACRAMENTO ROD <br /> LO€)I, CA 95242 <br /> 2091 339-7668 0 1 <br /> CtesrotseA rttaRaEA p _003 Oeuxac"Rt otsrrMMM! <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINERTYPE 2C. IDD.OF 21). VOLUME <br /> UN328I.Regulated Marty al Waste,a.o.s� CONTAINERS <br /> 6.2.PGII DOT-SP 13558 IM65 - Bios terms v s Tratas CAxt (59 cn ft) Cu <br /> UN3291 Regttlated Medical wage.mo.a., <br /> 0.2.PGI1 dKRB1 — BiaSvtstema Transport Box (4.3 au ft) .� <br /> p 8?.3PGE Reculged Mediegi wads.na.a. <br /> Cu <br /> Uj%11 Regulated Mefeal waste,Lox.. CU <br /> W UN3291.Regulated Medlin wawa, <br /> tZ 6.2,PGII Cu <br /> Ly <br /> 61 p2ji <br /> €tepulated Medloai araste,a.o s.. <br /> 6U.2,291 Regulated Medical waste.n o.s- <br /> PolCu <br /> 6 2 291FGIRopulakd Medial waste,roe L, <br /> CU <br /> �g z5V,G <br /> 3.Generator's Certbfloation,9 hereby doclare Ilial the eMents of urs wrtstgnment are fully and aocuratsly TOTALS 0. Cu <br /> descried above by the Proper antptpIn9 name,and are ctassirmd,packaged,marked and tabs"'Plaouded and <br /> are In an respects to proper for transportaxo Ing t a <br /> pplimbte International and nallanal govern ntat r m. <br /> I - [Ptintedff d Name —signature Date <br /> 4.TRANSPORTER 1 ADDRESS: Phone 0: G <br /> App %mm9fdmtiers6506 <br /> R 9'['Eit5 White Rock Rd ry r This is a Through Shipment <br /> YCLE <br /> TRANS)?OR'f�Qr�`cF. A� rpeA!;at waste as descnned above. <br /> Prkt0ype Name MVWA Signature Date 'r <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS; Phone Itt <br /> Appkcabie Permb Numbam, <br /> INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION: Recap of meoicai waste as dar,cribed above. <br /> P*IVTypa Name 817%awo Date <br /> 6.INTERMEDIATE HANDLES 3►TRANSPORTER 3 ADDRESS: Phone Y. <br /> gApplicable Permit Numbers: <br /> INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION:Recalpt of medal waste as dowbed above. <br /> = I <br /> PrfWTM Name Signalun€ Date <br /> 7,DISCREPANCY INDICATION <br /> Transfe C containers, �' OU tt to : North Salt lake, UT ' <br /> GA.DoVm ted F4011ty: 80.Alternate Fac IW. BC.Alternate Factflt . BD,Attemala Faclltty <br /> STEMCYC#.E.INC. STERICYCLE.INC. STERICYCLE,INC. 1 �Q STERICYCLE,INC. <br /> imq flnr rwiia rnivp crdta r. 4135 W.Swift Avenue 90 North 4100 West. 1812 Starr Dr <br /> i San I aanrlm ra 134677 FrpGnn rA 03777 North Snit Lake,UT 84054 Yuba City,CA 95991 <br /> (5101582- 1784 15591275-0994 (601)938- 1665 �a (530)755-{0585 <br /> Tq?i1 T'SlCI.ti"?7fi TSl05T 22 � z�Cr�gro� P-B,P-115 <br /> 11 TREATMENT FACILITY• ce ' that!have been authorized by the app a state a e to accept untreated medical waste and th have <br /> - received tIIB a to tes in accordance with the requireme d in t orization. 1 <br /> C a . <br /> Prtat?ypeNems G `�C� Signature Dak <br /> 1 <br />