Laserfiche WebLink
Rx Date/Time MAY-25-2011 (WED) 15: 35 P. 010 <br /> 05/25/2011 WED 15:45 FAX 1 12010/044 <br /> R i• 5teriryCle- W CASE OF EMEMENCY CONTACT.CHEMTREC 140042443M steNDARDIRAMMt oo1.104s M <br /> Route #: 912 32 Curtone>;Sift3ssWild9ft j DAC,0(1M;V <br /> 1.Generator's Name,Address and Telephone Number f [[ ff ]]## <br /> ATTN: Gavle Moses �lII��� � � I �11 <br /> BIO/LODI MEMORIAL HOSPITAL <br /> 575 SOUTH FAIRMONT DRIVE <br /> LODI. CA 45240 <br /> (203) 334-3411 3/4/2011 <br /> CusrvamNWraER 6089077-002 GoaRAronraa:mnowe <br /> RA.OESCRIt+TION OF WASTE 20. CONTAINER TYPE 2C. NO.OF 2ik VOLUME <br /> &ZP IiR°°'Aaw lam•' Imes - Bicsystew 5harpv Trans Cart (S9 ria £t) caKrAutEtls <br /> Gtt is <br /> UN3291.ftulatedhleftatwastn.aas.. MBS - Bio3vst=w Transaort Bos (4.3 au ft) <br /> 62,Kit Cu F <br /> d 6 II"Um MOW waste,tt os.. <br /> Car F <br /> Q UN3291,Regutaled WOW waste,n•o.s, <br /> ty 6.2.PGII Cu F <br /> BY UH3291 Regulated Medkal ttFute•a o s <br /> fi2,PGli CuF <br /> i ll Regr�ted WOW waste,&a.&. <br /> B <br /> CIA <br /> f <br /> 8N321H Reptatall Medical waste.e-Os., <br /> uF <br /> UNMI Reputed Medial Wash.ao s., <br /> 6.2,Poll <br /> Cu <br /> Baer lC• F <br /> 3.Genarator'a Cartifteatton:01 hereby deNare that the contents of this eonsignmerd are fufly and accurately TOTALS 170 ► F <br /> described above by the proper shipping name,and are dautlied,packaged,marked and laWedfolaearded.and <br /> are in am respeCta In proper Wdition for transport n applicable International and national govern tal r tatlons' / <br /> IAriMedlt Nama Signature90kDate 3 •1 <br /> 4.TRAN5PORTER f ADDRESS: phDTA6) 985 - 5506 <br /> Appacable Pernik Numbers: <br /> 13875 3rhite Rock Rd <br /> a 5TERICYCLrE Thi-3 io a Through Shipment <br /> a TRANSPORTI�1 1-t3 -"'- I waste as descdbed above. <br /> PWTVj a Name Signature Date <br /> 5.INTERMEDIATE HANDLER 2lTRA146MRTER 2 ADDRESS: Phone 0: <br /> a: Apptfcable Perrrdi Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described abets. <br /> P*WType Name Signawa Date <br /> S.INTERMEDIATE HANDLER 3/T RMSPOFrrEA 3 ADDRESS: Phone►: <br /> IS Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Recelst of medical waste as described above. <br /> z— PdnVrype Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Trarlsierr d_L_containers, ��cu it to : North Salt lake, UT <br /> Ot#A.Oesiguabd F=Mij ENIIX Akernate FsdMr. eC.AMemats F*411ty, OMAtterrrata Feellky: <br /> STI ICYCI. !RIG, �21�c'YCI, .INC. W�Y�.4NC. �CYCe.INC. <br /> t 34 Doore Drive.Suite C 1 S1�vlit Avenue o 1 West �B tart r <br /> San Leandro.CA 94577 Fresno.CA 93722 North Salt Late,HJT 84054 Yuba City,CA 85991 <br /> (5 10)562- 1781 15591 275-0994 A801)938- 1555 (530)755-0585 <br /> g <br /> Tsai. oRnz 'MOST 22 4ass%!Wdneted P 9S -ti.P.I t5 <br /> AVr0=VEO DALE ANNE p � <br /> Z d TREATMENT FACILITYi I'aertify that I have been authorized by tete applicable state agency to accept untreated medical wastes and that I have <br /> received the aboVeifidicated wastes In accordance with the requirement outlined in t7hat authorization. <br /> MARPrirrlrTypeName Stprlature I•YArry01 <br /> Data <br />