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�. auiilnauf 1�: s7 P. 044 <br /> 05/25/2011 WED 15: 56 FAX <br /> 0044/049 <br /> 41relo's SterleycIe' IN CASE OF EMERGENCY CONTACT:OMM CC 1406-624433 STAFraARp�eurtFf y pp�-sp p <br /> • h�7 Ayl►.rt.r.Agbtl�: <br /> Route : 413 V Cuatoscr l�o���� 1� (` (1 '" <br /> I.Generators Name,Address WS <br /> andT'elephone Number <br /> ATTN: Gayle Moses <br /> SIO/i:,ODI MEMORIAL WEST CAMPUS <br /> 800 SOUTH LOWER SACRAMENTO ROD <br /> LODI, CA 95242 <br /> 209 339-7568 2/2 <br /> cr>s�r�tet -Ons <br /> LiFxFAaion 9 ReceSnunprr fI <br /> 2A.DESCRtMON OF WASTE 29. CONTAINER TYPE <br /> ifh=.Regt>l w Wasfa n.oW, 20.NO.OF 211. VOLUME <br /> S 2,PGII OOT�SP 1556 RR63 - SioS teras SNTAINERS <br /> Y$ Sharps TransTa aas cart (59 ou ft) Cu F <br /> UH3291 RequWed Madkai ate no.e., <br /> 62 PG11 MBI — Bi93vatemz Transporb sox (4.3 Fu ft) <br /> M um3291 Regrrpttd Medica!haste nw.s, Cu F <br /> 6.$illi <br /> tlN3281,Reputated Medical>Vaste, F <br /> &Z PG1F <br /> Ill UNtpe I Regulated Maks Wale,n.0-j.. CU F <br /> Uj 82,P4iil1 <br /> ur UNU91 Regpkted Mrd Waste,n.o 5.. Cu F <br /> s.z PGIi <br /> UNMI Requiated Media Wute,n o s., Cu F <br /> MID <br /> U/I329t Regulated Medta1 Waste.n.04.. CU I <br /> 6.2,PGli <br /> R88I Cu F <br /> CU I <br /> 3,CmeMOey CertMCff on:'1 hereby declare that the contcrds at his Consignment are tally and accurately TOTALS ► <br /> are sq abm by the proper Whipping name,arxi are ctassffW.Packaged.marked and Iabegad►plar-0rded.end ' Cu F <br /> respects In prWer for transport e00ordirrg applloabtW Internstbnal end national nisi r 11�ts' <br /> �PrfnledlT Name S natu - ' <br /> 4.TRANSPORTER 1 ADDRESS: Data <br /> Phon <br /> '' AppN�at �l Nwrrrb6rsS0 6 <br /> 11875 W}rita Rork Rd ❑ <br /> STERICYCIZ X Thi-3 is a Through Shipment <br /> TRANSPORTER 918 JeftaffA221 waste as dewdbed <br /> PrinVType Name Signature Data �1 <br /> S.INTERMEDIATE HANDLER 21 TRAN3POAT�R 2 ADDRESS prc <br /> Phone r: <br /> M <br /> Apable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERT'IFICATI <br /> ON:Receipt of medical waste as described above. <br /> PrkrbTM Name Signature <br /> Data <br /> n 6.IM17ERMEDIATI:HANDLER 3/TRANSPORTER 3 ADDRESS: Prtorte p: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of meckal waste as deserltwd above. <br /> PrtntfType Name 8- to <br /> � re Date_ <br /> 7.DISCREPANCY INDICATION <br /> Transferred containers.q.3),ftto : Notch Salt lake, UT <br /> r Ilk Dealgrtatad Fssnity: MICYCLEANC. <br /> UMWe FeWhy: 8C.Altsrrrste F&:11 tj: BD.Aftmate FeClnttr. <br /> a ST RICYCLEANC, STEIRICYCLE.INC. STERIGYCLE,ING. <br /> It. 134f,f lnniitrtP tiriwa Rrrira f: 4135 W.SwiftArenue 90 NDrth 1100 West 1$12 Starr Dr <br /> h- Ran i Pandrn rA A4±577 Fracnn rA 0.1777 North Salt Lake.UT 64054 Yuba CitY,CA 85891 <br /> WO)552- 1781 (5691275-€1894 (809930-1555 (539)755-0685 <br /> TR?1 'I Stfr 51t TS/OST 22 <br /> Glass V Indneratian Permit#91 P-9,P--115 <br /> t¢ <br /> pt TREATMENT FACII ITY:i eerGly that I have been authorized by tht)-d}P W9 ANN�taQc45Tis sted medical wastes and that I have <br /> f— received itse above indicated wastes in acoordancp with the requirement outlined In that auttuuization. <br /> Prinl/type Name S(gn3lltreMAD 9flil <br /> �,„� � Date_ <br />