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Rx Date/Time MAY-25-2011 (WED) 15: 35 P. 016 <br /> 05/25/2011 WED 15:47 FAX 12015/049 <br /> 0�,10 steri[yde' IN CASE OF EMERGENCY CONTACT:CFtUMEC 1400.42443M srnNOMRo reu+n W 001.1040-M <br /> �.�•+w* Route #: 413 -2 Cu:;t=casT3 arF?ti&2ih3z 14DA ODA.MF <br /> 1.Generstoes Name,Address and Telephone Number 111111111111111111 <br /> �...�ENIN <br /> IitIIN1111111hTfiis s Gavle , ,05e✓ <br /> SIO/LODI MWORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LO€?I. CA 95240 <br /> (209) 334-3411 1/21/2011 <br /> Cus=XR NV=MtS "1'3-f l GE moR ms Rests uom e <br /> 2A.DESCRXrMN DF WASTE 28. CONTAINER TYPE 2C. NO.OF 21% VOLUME <br /> UN3291.itecuuted tile�Cal Wast nms, CtNlTAt ERS <br /> 6.2,PGII DOT-SP1=6 1P65 - Piospstems Sharps Yratss Cart (59 ¢u ft) <br /> + CU <br /> UN3281 Reawated mukal Waste,n.cs.. <br /> U.PG !{F58 — Eiosvbt z+_ Transport $tx (4.3 cu ft) <br /> fs tJN3291 Reytrlattd Mediu Waste.nes. Cu F <br /> p 6.2,Pei F <br /> i Regaum media)Waste,A.0-s"6Z PGI <br /> Cr <br /> F <br /> W UN3291.ReyuiWd MedJtal Waste,ao.e. <br /> tZ 62.PGII <br /> UN3291Re MPP hlediral waste.6.0A, a'F <br /> 6-2.PGIi <br /> Cu F <br /> UN3291 Requatcd Medical weue, ms., <br /> 6.2.PGI! <br /> a, [I <br /> 8PG1.Reed ded MediCal Waste,1),03, <br /> 6.2. <br /> CUF <br /> qrf <br /> 3.Generator's CerMatlon:1 hereby dud=that the oantente of Vt s Consignment era 101y and accurately TDTAt.S ► 1.Q iv <br /> described above by the proper shipping name.and are dassirred.packaged,marked and IabeffaftlecaNgd,and Cu I, <br /> are In all respeote In proper Mon For transport socardIM to applicable international and nadonai pwamme tal regutatlons.' <br /> 4,1111) <br /> 1PrWWvTyW Nam Signature Date <br /> 4.TRANSPORTER t ADDRESS: Phos <br /> Appr�tadd F8m>fl(lumbers 5 S 0 B <br /> 11895 White Bach Rd ❑ <br /> -Vl <br /> 3TAICYCLE `If This is a Through Shipment <br /> a TRANSPORTF� P13* , waste as desonbed <br /> PdrrVType Name Signature Date •i <br /> 5.INTE RMEDIATE HANDLER 217 S RTER 2 ADDRESS: Phone R: <br /> Y <br /> Applicable Permit Numbers: <br /> = INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpt of medical waste as described above. <br /> Pdntffype Name Signature Dale <br /> i6.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone 0; <br /> � � AppllOahle Permit krunbere: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Rowipt a msduai waste as described above. <br /> Pdntnrype Name SFgnatm Date <br /> T.DISCREPANCY INDICATION Q �} <br /> Transfe d 17 contalners,21 !� cu It to-. Noah Salt lake, UT <br /> D 8A.t?oaFpnafed Fecntty .Aromats ra iinyt .Artemets Faalty ao.Altemete Faclitty: <br /> h <br /> STERICYCL.E.INC. STEM CYCLE.INC. STERICYCLE,INC. MRICYCL.E,INC. <br /> t&C 1345 Dooltile Drive.Suite C 4135 W.Svvift Avenue 80 North 1100 Wei 9552 SmiT Or <br /> M San Leandro.CA 94577 Fresno-CA 93722 North Sall Lake.UT 34054 Yuba C. ,CA 85991 <br /> (6 10)502- 176 9 (559)275-0994 (8011930. 1555 f6301 79-05$5 <br /> TS31�N�i� � �.y T&OST 22 bas's V tnoisle i P-e.Q-i 15 <br /> CClllA13 tito it TREATM6�IT FACt TX;I certify that I have been aulhodzed by the app, e s a e agency tept untreated medical wistes and that I have <br /> received the above indicated wastes In accordance with the requirement outlined In that authorization. <br /> PMVrype Name Stpnature Dam. <br /> S2 <br />