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Rx Date/Time MAY-25-2011 (WED) 15: 35 P. 615 <br /> 05/25/2011 WED 15:47 FAX 2015/049 <br /> V* Sterleycle' IN CASE OF EI FAGENCY CONTACT:CHENTREC 14004244M STANDAAa MAMFesT 0DI-t04&M <br /> as ►v.�o,.,�u•r•�arre Route $: 4i3 4 Cu�toaCtlSTirisFJ£N1d'2£132 MDRC00ABTY <br /> 1.Generator's Name,Address and Telephone Numttet' 111111111111 <br /> ilMUNN <br /> 111111110 <br /> 11ATTN: Gavle Ko5ea <br /> BTO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> (209) 354-3421 1/28/2011 <br /> CVs7am Nuuun 608907 7-002 GURRA ort-e REC*Mt x;K e <br /> M DESCRIPTION OF WASTE 20. CONTAINER TYPE 2C. ND,OF 20. VOLUME <br /> UN9291,Regutated f CONFAINEAS <br /> &2,PG11 a I�6i — BiaSystems Gkazpx Izeas Ciszt (54 eu ft) . Cu F+ <br /> BuZ PCIt �C tedMWicDlWaste.uos. RABI - Bio3V%t=r mran_rort Box (4.s au ft) Cu <br /> F <br /> cc G 6� Requtaled Medial ftte,n.o.s_ <br /> .2PGI( Cu Si <br /> Q UN3291 ReguDled Me41al Waste,n.04- <br /> IX6.2,PGII Cu F1 <br /> LU t1F MI.Reguingif Medial Warts.a.os., <br /> W 6 2 .Pen Cu R <br /> UM3241 Regulated Medica!Was1r,n.oz, <br /> 6,2,PGII <br /> Cu FI <br /> 03"1 <br /> 82, !ftegulate4 lwetnca!14as1e,AAA., <br /> Cu FI <br /> UN3291 Regultled Me"Waste,n.o s., <br /> 62.PC Cu A <br /> Qu R <br /> s.Generators Certifkatlon:11 hereby declare that the contents of this conslgnmeM are[Lay and amr4tely TOTALS ► '7 cupt <br /> 4ese0de4 Ochre by the proper ftpN nacre,and ars dasslaW,packaged,marked and lahe4ted %carded,end <br /> are in all respects In proper 10iftA fora <br /> i to applicable international and national gove n1al regulatio <br /> 1 !PdrvtW Name S' I Date <br /> 4.TRANSPORTER 1 ADDRESS; Pho"eftt') 985 5505 <br /> � <br /> APOI a ale Permli Numbers:11875 white: �¢r. Iia <br /> < 8'I'£RICXCLrE Thiv iW a Through Shipment <br /> d <br /> TRANSPORTER 1�G ,tom'1pr9rrFm*7 waste ffi described ab <br /> PrinUfype Name Signature Doe <br /> 5.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phare is <br /> N <br /> Applicable Pemdt Numbow. <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:flecelpt of medical waste as described above. <br /> Nrinfte Name Slgnatura Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPOF;TER 3 ADDRESS: Phone a: <br /> a: <br /> Appricable Permit Numbers: <br /> INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION:Recelpt of medical caste as desulbad above. <br /> I'drrtliype Name Signature Date <br /> 7.OISCREPANCY INDICATION )�,�- (J <br /> Transfe etf Z1 Containers, - 9cu ft to : (North Salt lake, UT <br /> r Q BA.OnIgnated Facility: 00.Aitentets Fecghyr ec.Attsmft Facing. 8D.AReinate FeGbry: <br /> C S RICYC�, INC. g�RI C 1NC. 1 Y NC. g CY�� INC. <br /> 1 5 Dtlalitile Df'I�!e�. tfite G A 135 SAv nue 1 �ast <br /> SartLeandro. 9457 Fresno.CA 93722 North ak Lake UT 84054 Yuba may,CA 95991 <br /> (510055-1081 (559)275.0964 (801)930-15515 S 5 <br /> (530)7s -058., <br /> � T� A„o��;, a.��}t� �r�,l�s�z� DA4E {ANNE �7 FST' Zet p-s,P-j 15 <br /> TREATMENT FACILITY:I certify that I have been authorized ty the applicable State agency to accept untreated medical wastes and that I have <br /> t- received the above indicated wastes in accordance with the requirement outlined in that��`hor 11 tion. <br /> P,;ntArypet�ame signature ina1 Date_ <br /> .� 42� A t <br />