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Rx Date/Time MAY-25-2011 (VED) 15: 35 P. 018 <br /> 05/25/2011 WED 15: 48 FAX 12018/049 <br /> IFA• Steri e' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1.800.421-M STANDARD MANIFEST ooi-ioa"TD <br /> !` a+• . •e•�.rna Route #: 413 i Cuetometas aRKWi32 M1)AC00AB3E <br /> 1.Generators Name, <br /> �YAddl�ess agnd Telephone Number <br /> 1 1 [lilt� 1111111��� <br /> SIO/LORI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI, CA 95240 <br /> 2091 334-3411 1/7/2011 <br /> G�1Sr4a1tEii Nui[BER <br /> rnROA-17 —002 tIFJ mTon's RFGMMUTIDN• <br /> 21L DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. ft OF 20. VOLUME <br /> UN3281.RegulaW Medical Waste rrAs.. CONTAINERS <br /> 6.2.PGII DOT-$p 1 MR65 — BiaSpsec»as Sharps Trans C4xt (59 Cu ft) 2. All <br /> UN3M82 II Reg tedMediwlWasta,e.os., Kul - biosystems Trarspart Box (4.3 cls ft) <br /> Cu <br /> Q UN3291.Regulated Medical Waste,4.0's"0 6.2.PGII Cu <br /> UN32311.RMWAd Medical Wase.n.0.s_ <br /> 62,PGII Cu <br /> W UN3291,Regulated Medical Wash,ox.s., <br /> W 6.2.PGII <br /> 0 CU <br /> UN PG 1 Rtg�ed Medical Waste,n.a.e., <br /> U 291d FiWAated Medical Waste,d.o.s. Cu <br /> , <br /> U1�t32A1Regulated Medicalste <br /> Wa ,n.as„ <br /> Cu <br /> 6.2.PH <br /> i <br /> Cu <br /> 3 Generatcea Canifteatlan:"1 hereby declare that the contents at this constgnmenf are tartly and scquw* TOTALS► <br /> described above by the camper shipping name.and are c(assitled,packaged,ma*ed and labetledlptararded,and Cu <br /> are In all respects in proper Coulon tot prisport according 1 applicable Iraternafionsf and national goner fatal re Wlons,' 7 1 <br /> I - 1Prinl Name Signature Data <br /> - 4.TPJ1N3ppfiTER 1 ADDRESS: <br /> Phonre q: g�5 <br /> 11875 Whitt Rock ltd Appti�agbearmll hEumber 506 <br /> STERICYCLE X 'Phis is a Through Shipment <br /> TAANSPORTPEIP�f waste as described above. <br /> PMV1'ype Name Signature Dots_.j 7.1 <br /> S.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRE5S: Phone 1: <br /> i Mplicatrla Permit Numbers: <br /> , <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described ahwa, <br /> Printfrype Name Signature Oat% <br /> 6.INTERMEDIATE HANDLES 3!TRANSPORTER 0 ADDRESS: Phone Of., <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION.Receipt of medical waste as described above. <br /> PrinViypa Na Signature Dale <br /> 7.OTSCREPANCY INDICATION <br /> Transferred Containers.;!)-`r'?C11 R to : North Salt lake, UT <br /> Q&A.Daslanarted PacoitY: as.ARaraate racnityt go.Alternate Fecllity- 00,AWwrtate Favi ft. <br /> STERICYCLE-INC. ST[:RICYCLE.INC. STERICYCLE.INC. STERICYCLE.INC. <br /> 1345 Doolittle Drive.Svlte C 4135 W.Swat Avenue 90 Nonh 1140 West 1612 Starr Dr <br /> San Leandro.CA 94577 Fresno.CA 93722 North Salt Lake,UT 84054 Yuba City,CA 85991 <br /> (510)562-1781 (5691275-0994 (80 to 038-1555 (530)755-0595 <br /> I TS3i.TS(OST26 tWST22 CiassVir�dneradan Pemil*tai �tt -115 <br /> - TREATMENT FACI[.I shat I have been authorized hY the applicabI state a a et medical wD7� <br /> dt I have <br /> received the ndicatndicat antes in acaccordanos with the requirB ned i ri a <br /> V �PdnVrype Name Signature G f DateCJv <br />