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Rx Date/Time MAY-25-2011 (WED) 15: 35 P. 917 <br /> 05/25/2011 WED 15:45 FAX 12017/049 <br /> we <br /> • Stet cycie' IN CAK OF EMERGENCY CONTACT;CHErrfTREC I-BOD 4244= STANDMI)U InSr 004.10404M <br /> s• „ ,�,�,�„�,,�,,,• Route : 413 4 Custcmea; N6.21132 MDROGAM <br /> 1.Generator's Name,Address and Telephone Number [[ (( }} [ <br /> ATTtt. Gavle Motesf� 11 � � �� 1 <br /> SIO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVS <br /> LODI.. CA 95240 <br /> (209) 334-3411 1/14/2011 <br /> CtrsrounNUUM 6089077-002 OvapAmrsRE=rmwm• <br /> 2A.13 SCRIIMMOFWASTE 2S. COWAINERTYPE 2C. NQ OF 2l} VOLUMtE <br /> 1IN0PG1I IKR65 - SiaSystems Sharps TransERSns Cart (S9 cu ft) r <br /> Cu <br /> IJN=1lF4WaudMedfcalwaste.e.0X. 1{R81: _ Bio$vstemz Transport Box (4-3 cru ft) <br /> Cu_ <br /> lu Wil,Requt w molt vnsta,n o.s, <br /> FF UNMI RaOataudMeOicatlNaste,++.as, Cu <br /> Q 6.2,PGII <br /> Cy <br /> Z 5.2 Pl;ll Re UWW Medica! ste <br /> wa .a,0.s.. <br /> t7 6UNMI Regulated meftat waste.n a <br /> PGICu <br /> umni,ftegubted Medical Waste, <br /> OZ.Poll <br /> t <br /> U113291,Reguftd Medical Warta,nAS.. <br /> 6.2,PGI! <br /> RRBI O <br /> Cu I <br /> a.aeneretces CeAmcation.i hereby declare ow fire contents of this conslonmem are futiy arta aceuratety TOTALS►1: ,$ <br /> desalted above by the proper•shipping name.and are classified,packaged,marked and labett olamrded,and Cul <br /> are in an respects In proper cVdO,for transport to appAccable Imemationat and national Bova tal tegutafiorle <br /> XPrinledrtyped Name at tku <br /> nett Dake <br /> 4.TRANSPORMF1 1 ADDRESS:. VPhar��rYE) gs}w — S5D6 <br /> 21076 White Rock Rd ❑ Applicable Permit Numbers: <br /> This i3 a Through Shipment <br /> g <br /> TRANSPORT 0ieFIQ0%P &waste as desafbed abol. <br /> 0r1nVlype Name Signature 4=4 Date <br /> 9.k INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone 0: <br /> ~ APptic"Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medicat waste as dasoftd above. <br /> Primfrype Name Signature Data <br /> 6.fNTERMED1ATE HANDLER 9!TRANSPORTER 3 ADDRESS: Ph"4: <br /> Applicable Permit Numbers; <br /> INTERMEDIATE HANDLER I TRANSPORTER CERTIFICA116N:AWAIPt of medkai waste as described above, <br /> Prfni/Ty"NamB Slgnalure Data <br /> 7.DISCREPANCY INDICATION �t p <br /> Transfericed Containers, �U4 cu tt to ; North Salt lake,LIT <br /> Q BA,00419alted FOOMr. M11111.Alfemets FedtW. 8C.Attemeh Fek:llhy 80.Attamou Factaty: <br /> S R CYCLF INC. C INC. oI Y1C� Nt:. gff ,INC. <br /> 14 ii an ea4"1rtle F7 gg e C fftleSnF q 15891 <br /> w $an LeandroCA57 �R37Y1�1 I�o ak 1 akQ 84054 Yuba Iry. <br /> (50 562-17B# (559)275-0994 (801)835-1555 (5307 755-0585 <br /> T531. S(OST25 MOST 22 i'-B,P-1 t 5 <br /> TRI AWENT•FACIl.t;1Y:I certify that t have been authorized by the applicable state agency to accept untreated medical wastes and that I haw <br /> received the above Indcated wastes to accordance with the requirement oullinedfIlhet <br /> P rdrype me Siaaaturo MIY ` <br /> DID C_`8 <br />