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04n l i—Gull P. 014 <br /> 05/25/2011• WED 15: 47 FAX 2014/049 <br /> ai o6 Ster{cyde- IN CASE OF EMERGENCY CONTACT;CHF. REC 18oa a24 9300 Sn a►uHIMST opt•to S'm <br /> +*�rh.w�..�►,o. Route : 413 e CuVtCmMTftAk0A32 M C-00AN R <br /> ��i•Generator's Name,Address and Telephone Number (� <br /> ATTN: GaYie Mases <br /> BIO/LODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAI RMONT DRIVE <br /> NODI. CA 95240 <br /> (209) 334-3411 21412011 <br /> currold" 60 9077-002 GEwtmtowsRuntw,norrtr <br /> 2A.DESCRIPTION OF WASTE 29. CONTAINER TYPE 2C. NO.OF 20VOLUME <br /> BzrollR` 1t°� •. RRSS - BioSTst*=X Shnrpz TrAnX Cant (39 Cu ft) CONTAINERS <br /> UN3291 AVYWW Medical <br /> 62.PGI1 Waste.nos. WX — Bi13y3t:ema Tranwport Bax (4.3 au ft) Cuf <br /> M UN3291,Repulaled Metilral Waste,nA S. Cu F <br /> O 6.2.PBII <br /> 6U2�PQiI Mated Memw Waste.mos.. Cu F <br /> 1t7 .Z P 1Gti <br /> 6RapnW MiR Waste moll Cu F <br /> 8.t; <br /> �+ <br /> Pt1p Uti3291.ReOUlated Medkal Wane,&M C„F <br /> 6 2, <br /> 1,1111111,314111:111 <br /> RdMedlpl Wasu.ncs,6�Pil f <br /> 8. %dated r+l'80k WWaste,na.s, Cu F <br /> Il88IF <br /> 3.Generator's Certificatton:"1 Hereby declare U+al the Contents of this consignment are fatty end axuralely TOTALS ► <br /> are indescr09 sP00bove by ire proper shiPAbV»,and are ChMired.Padraged,marked and tabaftedlplacarde(.end Cu F <br /> are W aB respoCtg in proper=WIIbn for lrenspon a000rding to appilcable inlemational and nallonel awamunerifal r tionslip, -101 ' <br /> iPrinte Name&—a-4A .� <br /> 4.TRANSPORTER 1 AD SS. Date 2-7 <br /> fie) 985 - 53a5 <br /> 3187$ White ROLk Rd Appkabla Parmil Numbers: <br /> STCRICYCLE This fa .n Through Shipment <br /> I TRANSPORTS JU .fQ6jprV;Xjj&waste as delated abWA <br /> Prkdrype Name signaluro <br /> 6.1 HANDER 2/TRANSPORTER 2 AD RESS: Pate <br /> � Phone r1: <br /> ApPIiCable Por"Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as despWed above. <br /> P*WType Name signature <br /> eta <br /> t INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: <br /> ?hone►: <br /> APPR*bte Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medial waste as described above. <br /> PdnVPjpe Name Signeivro Date <br /> i.DISCREPANCY INDICATION f y� <br /> Transferred 1 V Containers, L cu A to: North Salt lake.UT <br /> r E)BA.Desi mmw FecIR7y: 88.Akern to Fedilty: BC.Alternate Fadity: BD.Altometa Fsd <br /> C �� �� �yG <br /> � 11e DrNn+ .Suite C �W. <br /> Swift �otsh f 1 C. CE,INC. <br /> Sap!Le2frift.CA 44577 Fresno.CA 83722 North Salt Lake LET 84054 Yutta C' ,CA 05991 <br /> (51 43 582. 1781 1659)275-0094 ' <br /> TS31.TS1©5'il''2s foot)930-155 530 755.0585 <br /> F � �a j� TSfOST22 C4assVitrot:it►etatiat� F+ettri 81 -8, -tib <br /> ClA .F. ANNE ORTIZ <br /> TREATMENT F=ACILITY, I cerlity that 1 have been authorized by the applicable state agency to accept untreated medical wasles and that I have <br /> received the above indicated wastes In accordance with the requirement outlined in that aulhorizatlon. <br /> PrWNype Name Sigeature R 17 2011 <br /> •.,, ...„ J(�� (f/] Date <br /> e'0.�►R• 4 A tti./.f..�� f^—'riiw J' i <br />