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pin /'j-LUII 1.wnu) 17: Sy P. Q11 <br /> 05/25/2011 WED 15:46 FAX <br /> ®011/049 <br /> i*♦� 5terirycle, IN CASE OF Ektt:Rt;ENCY CONTACT.CHt:iTtREC 1 8Q0.42q.93op STANDARD Route #; 913 �1 Cu3tG ME MAMFEST001.169&STD <br /> 2932 mnnr-00AGj0 <br /> 1.Generators Name,Address and Telephone Number <br /> Al ilii Gavle HOSPITAL <br /> SIOlLODI MEMORIAL HOSPITAL <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> 1209 334-3411 2/2512011 <br /> CuFFUM tK AIDI x <br /> O�+uoa's Rt:atsrgaTtoer f <br /> 2A.DESCR#PnON OF WASTE 2H. CONTAINER TYPE <br /> . # 2C. NO of 2p. VOLUME <br /> 6.2 Pcii od UaT� 1i�.5s - BUSystcas 5basps Trmw Curt (59 Cu ft) <br /> S Q� <br /> UNM Regulated Medkal Wuu,e.o.s_ f! C.I <br /> 6,2.PGli RRB$ - pj*3 vtcmn Transport Box (4.3 ru ft) <br /> O6U K Pae�atated#�teaicat Waste n a s.. Cu I <br /> ,Q UN3291 Regulated Medd Waste.a.o.s., Cu f <br /> 6.2.PGI# <br /> {f1 tIN32atAeputated Medkal Waste.a os Cu# <br /> 6.2.PGIi <br /> C9 UNMI Regulated fttedleal waste,a.e4, <br /> 62. Cu i <br /> 1`611 <br /> UNMI R09+aated MWIWJ waste,n P s., Cu I <br /> 6.2MIIi�tdated Medltal wash.n,es„ i <br /> RXB1 Cu f <br /> 3.Oerteretcr'6 Certification:9 hereby declare that the contents of this consignment are Wy acioged.marked and and accurately TOTALS ` <br /> described above by the proper shipping name,and are dassffled,p <br /> are In ell reSpe4la!n proper 00 Ilion for Uansport 6000rttirig tt!8pp#i a Fntemalional end na lacan �r W Cv# <br /> I � regNatlena" <br /> Pate Name <br /> 4.TRANSPORTER f ADDRESS: tum Date <br /> Rbc fits) 995 - 5506 <br /> d 11975 White Rock Rd APPifcabla Perm€1 Numbers: <br /> STCRICIPCLE This is a Through Shipment <br /> a TRANSPORTM lTUq RQAAM16 waste as described above <br /> PrtnUType Name ff <br /> Slgneture Dei@ x �'�� <br /> H <br /> 5 INTERMEDIATE HANDLER 2 rTRANSPORMR 2 ADDRESS: <br /> Phone e: <br /> AWkwe Permit Numb@ry: <br /> INTERMEDIATE HANDIER/TRANSPORTER CERTIFICA71ON:Receipt of medical waste as described above. <br /> Pdrilf pa Name Signature <br /> Date <br /> » S.INTERMEDIATE HANDLER 3ITRANSPCRTER 3 ADDRESS: <br /> Phone 0: <br /> Applicable Permit Numbers: <br /> i INTERMEDIATE HANDLER!TRANSPORTER CERTIFICAMON,Receipt of mediad waste as described above, <br /> PAWTou Name Signature <br /> 7.DISCREPANCY fNDICATION Date <br /> Transferred oontalners. S f-07 Cu ft to : Mirth Salt lake. UT <br /> r � ❑BA.cbstynated fiaaally: ,Alternate Feel, — - <br /> a ity. 8C.Atterndte FeciAty: @a,Altsmate Fadtay: <br /> At IRIGY� INC. CLS.INC. RtCYCLE INC. STER#CYCLE.ItVC. <br /> J. SM <br /> 345 Doal>t>ie DEive_Suite G 4 t�W,Shift Avenue 9D N drib f 1 t7p INC t 612 Starr Or <br /> San Leandro 94577 Fresno.CA 93727 North Salt lake,HJT 64054 Yuba Gt'ry,CA 95994 <br /> N f510)562- i 761 j f559)275-0984 901)938- 1555 (530)756-0585 <br /> LAVEDSZ �. 1 TVCW 22 GtassV tr%dt1ET'adan Perms 91 P-6,P-t 15 <br /> L AsNNE ORTIZ <br /> Y 01, TREATMENT FACILITY:I rerGfy that t have teen authorized by the appllcabte state agency to accept untreated medical Wastes and that I have <br /> received the above4ndicated wastes in accordance with the requirement outlined In that auutortzation. <br /> PrtaVTM Naov MAR 0 9 2011 <br />