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_•.� rnnl-L7-6U11 (1iht1J 15: 35 P. 013 <br /> 05/25/2011 WED 15: 46 FAX 2013/449 <br /> Or <br /> �70 Stericycle'�• h�..��ee�erll IN CASTE OF EMMGEKy CONTACT:CNEWMEC 14OM4jj3pa SMI)ARD VANWEST mt•tooet VM <br /> Routes M CO AE344 <br /> i.Generator's Nance,AddMas and TelePhons Number <br /> ATTN: Gavle Moses <br /> BIOlLODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> f1A1 2 1.2 201/ <br /> c uroxER I ei>xtRn a t eaeTlunori r <br /> 20.DESCRIPTION OF INAW T877 CONTAINEA TYPIC :tC No.ol* 2a "LUME <br /> tim6 E, ed R"911 Medlrel Waste,043, t:ONTAI ER5 <br /> RR85 - Bi.o5 --teem Ghaxyq Trans Cart (59 cis ft) r Cu FL <br /> UN3291,AnUtated MOW Waste.mos, <br /> 6.2.FGil RRBS Bios stem= Tran5vort Box (4.3 sus it) <br /> WUN3291.Reputed Mt�l W,nte,p.", Cy FL <br /> 6.2.PGiI <br /> Q WM91 Repotated Medkal Warta.leas. Cu Ft. <br /> M 62,P61i <br /> UJ UN3293,Repubrted MediW Wa L n os, Cv FL <br /> Z $.2,1,511 <br /> (3 UN3291 Reputated Medktl Wi9c,n a.s., Cu FI <br /> 6.2.PGI1 <br /> Ifff3281ri Regulated f�ktlkal wtste.n.os, Cu FL <br /> r,.z,f� <br /> syvn Reptrfatw Ile IMI Waste•n.o a. Qu FL <br /> Cu FL <br /> BT <br /> 3.Qene WWW CO"Iflcatlon:'I Hereby deCfare that the contents of cede consignment are tufty and accurately TOTALS ► �� l�T •�$' <br /> described above by the proper shipping name,and are elasstlied.packaged.marked and labs Cu Ft. <br /> are In alt respects In proper owdillon for trans usdrpte,$rdad,and regulations' <br /> port=C=ording to applicable Intematkxtat end rtatlortat govgr Heal <br /> f /Print Name <br /> S' nature Date <br /> 4.TRANSPORTED t ADDRESS: <br /> Phone p:a qq <br /> APpl rgrmqltNdrret;-0,Ps06 11875 White Rook Rd <br /> R$ STICTILICYCLE This is N Through Shipment <br /> Q,rQs TRANSPORTM&C 3 PVN" <br /> � Ipg45+R at wrests as described strove <br /> PdnVtype Name }�K <br /> Signature <br /> oate• <br /> 5.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone 8: <br /> N <br /> Applicable Pefmll Numbers:INTERMEDIATE HANDLER/TRANSPORTER <br /> CERTIFICATION:Receipt of medical waste as detloritied aDov,e. <br /> PMVfiype Nwne Signature <br /> Date <br /> r`a Ly <br /> S.INTERMEDIATE HANOI.ER 3/TRANSPORTER 3 ADDRESS: <br /> a Poona a: <br /> AppGcabta Fam4t NumOers; <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receolof merrrcal waste ea described above. <br /> PrinNTy;o Name Signature Oats <br /> 7.DISCREPANCY INDICATION <br /> Transferred.r r contafners, W-W Gu ft to: Nodh Salt lake. UT <br /> r y Q�Bfi.BeslgnaM�FeCarty 1 Alternate Faculty,aC.Anernste Factafy: ED.Alrnrrral0 F�tlayt <br /> fj <br /> 9��Atrf nue Watch t 1 9�at �fr�`INC. <br /> San Leandro.CA 045777 C Fresno,CA 03722 North Salt Lake UT 84054 Yuba G' CA 85991 <br /> f510)562- 1781,E A NE O� (559)275-0094 Icy <br /> raa t rcfncT�� �pct.A�D Tyr 801 j 938-155= (5S0)75 -0585 <br /> 1 MVI. ..„...,.. ..„OST 22 ,.la V i erddan Dema 2A P-B,PA 15 <br /> DA E W ME ORTIZ <br /> TREATMENT FACIE ITY:I certify that I have been authorized by tete applicable State a e to accept <br /> l` received the above Indicatteed�wastes in accordance with the requirement outlin d i thea to hodza .untreated medlCW wastes and that I have <br /> Pd-Vl"ype Name ffJ�' Signature R z 3 2011 <br /> Date <br />