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-�, •W� n1n, -GJ-4U11jWLV) 19: 15 Y. 012 ` <br /> 05/25/2011 WED 15: 45 FAX 12012/049 <br /> *a Stcri...cl <br /> tl•a. t eO:F RGNCY CONT6u :CHEMTRE ANOAN� <br /> tr� to,.t'o-89 4 MDRC6DrAFtaeesro <br /> i.Generator's Nattne,Address and Telephone Number <br /> 4 IN: ISM"le <br /> BIOILODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI• CA 95240 <br /> (209) 334-3411 2/18(2011 , <br /> mut trsen 7—002 <br /> t3EJ+FR»OAB Ree:Jsrx&s,vlt fe <br /> 2/L OMFIIMN OF WASTE 28. <br /> bH329t, A�rdt�Was CONTAINER TYPE <br /> RWaud 2C. N0.OF 20 <br /> $.2,fCrl oOTsIT{P3y Kit65 - Rio$ teas SONTAINER VOLUME <br /> bax�ts Tracts Cart (59 Cucv ft) <br /> UZKIi> 1Nedxalfit►aste,n.bJJ, $ 4 Eie9vatems firanvoort Bax (A.3 cu ft) Cu Ft <br /> ¢ W3291.Aegr:kted mwica!waste,a., s.. <br /> 62.PWI ctr Ft <br /> Q �f Aetlufated Jbedkat wast&,n.os Gr A <br /> tW� UN32flt Fequtate4 Metlica!Waste,n.as., or 1=l <br /> {Z C <br /> 62,PG1I <br /> � 5.2�Ij Reputated Medical waste.n.oa.. Cu Ft <br /> UN3291 Regulated Medical waM.rl os., Cv F <br /> 6.2,PGIi <br /> UN3291 Regulated Meftx waste,n.e s C,J F <br /> 6.2.PSli <br /> 1'i$HT Cu Ft <br /> 3.oenerator s certification:-1 hereby deriare Ihal the contents of this jOu <br /> de8"tcd above by the proper Shipping name arra are cra$0 oorrsignrnent acct fully and aoauatey TOTALS i► <br /> are In ail respects in Proper Dart for irans .marked and labetle Vplacanded,and <br /> " a 10 a0ficabla intem ijonal and national govern oral reguia ns.- <br /> Name <br /> s' <br /> !Jame <br /> 4.TRANSPARTER t ADDRESS: Date ' <br /> a 11875 White Rock Rd Ft10!Wis) 985 — 5506 <br /> Applicable Per=Number&: <br /> rn S`I'CRICYCL£ Th-is is a Through Shipment <br /> iL TRANSFORM A pNA0jQW waste as desvbed above. <br /> PnnriType Nerve C>Jum <br /> _„_S;grrature Date <br /> 5.rNTERMEDIATE HANDLER 2!TRA S RTER 2 ADDRESg: <br /> n <br /> Phone e: <br /> Applicable Perms Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above, <br /> PJin0ype Name <br /> Slgrmtvre Date <br /> +� 6 INTERMEpIATE HANDLER 9 i TRANSPORTER 3 ADDRESS: <br /> Phone.; <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTTFlCATION: Appocibts Perrrdt Numbers: <br /> Receipt of medical waste as described above. <br /> Prinvrvm Name <br /> 7.DISCREPANCY INDICATION Slgnatvre Data <br /> Transferred containers.5L cu ft to : North 5ait iake, UT <br /> Q 84 t�eslpn&ted Faeltfty. 9.AbMU trFedti}y <br /> ec.Attamat.F.cruh: eo.Ahen+at&F&crrny: <br /> a b`T1:RICYCL.E.INC. S7ERICYCL.E.INC. <br /> eL 1345 Doolktle Drive.Suite C STERICYCL.E INC STERICYCLE INC. <br /> 4135 W.Sw t Avenue 80 N onth 1100�1►es[ <br /> w San L.eandr D.CA 84577 r 1512 Starr Or <br /> (510.1562- 1781 e91a�1)j 1 Fresno.CA 0„722 North Salt Lake.UT 8405q Yuba C' CA gggBt <br /> X5591275-0984 <br /> 2 TS31.TS(OS�OCNLEA1 E� (801)920-1555 (530175_y,- A g <br /> TSI�sT n D Lri�b �`lC� ° � <br /> u� _. P-6,P-515 <br /> Q TREATMENT FAC1LlTy:.I,Certfty that i have been atJtl,orfxed the <br /> F received the above Indicated wastes in accordance with the requirement applicable <br /> outlined�i,ln that agency to untreated medical wastes and that t have <br /> Fnrwry;*Name MAR 0 2 L r J <br /> Signature <br /> Date <br />