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Rx Date/Time MAY-25-2011 (VED) 15: 35 P. 009 ` <br /> 05/25/2011 WED 15: 45 FAX 0009/049 <br /> O.49 5lericyCle• C� i 't qq d <br /> 0 0w.w Ro teJIS OF R CT C�STo�21 t32r ��A{t�ytANlFesr oar•,ae8 ssR <br /> 1.Generator's Name,Address and Telephone Number 11 1 Nis <br /> AT` H: Gwle Kozel, 11 1111 1l 1111I S I <br /> BIO/LORI MEMORIAL HOSPITAL DOW,%. <br /> 975 SOUTH FAIRMONT DRIVS <br /> L00I. GA 9S240 <br /> (209) 334-3411 3/2 ./2011 <br /> CUS?VM NUMBER 60 F8q 017 —002 ca+saArorre REr.%MVDN <br /> 2A.DESCRIPTIONOFWASTE 213. CONTAINER TYPE 2C.NO.*F 21K VOLUME <br /> U193291 Aegbfaaed <br /> 612.PG11 WERS <br /> t s" Y.R6S - BioSprtdms Sharps Trans Cott (59 cu ft) CU Fr <br /> UrJ324l,AegulatedMedkalWage,nes» 1{RSff - Bi*3v--ttoas Transport Box (4.3 ru ft) <br /> 62,PG{I <br /> W UI13P91 Regulated Medical Waste,CLO-6, Cu Fl <br /> 62,P61 <br /> cc6.2,,PGI!Repulxted Medical Wash.e.a s Cu Fr <br /> W UN329t.Repulatt.d Msiiwf Waste.n os, <br /> W6.2.PGit <br /> UN3291 RsQutaEetl Medical Waste,8.98» Cu <br /> 6.2,Pal[ <br /> UN3291 Regulated Medkal Waste,n.as.. Cu <br /> 6.2.PG1l <br /> WM91,Regulated Medhml Waste.a,e.s» Cu Ft <br /> 62,PGI] <br /> rl <br /> Cu F1 <br /> It$sz y 3, 2 <br /> 3,asnaretorb CmUficetiont'l hereby deMm that the oonlents of this consignmeru are I^and accuratety TOTALS i '� . <br /> described above by fire proper shipping name,end erre Classified,��11Od marko and label Cu FI <br /> are In all respects in proper ition for transport axo irrg to a �'and <br /> IV, pliCablg international and national gavemmerrtal regulations." <br /> IPrint Name S nateDate <br /> M 4.TRANSPORTER I ADDRESS 6�QPito <br /> `rdi 9b5 - 550 <br /> 11875 Whirrs Rock Rd <br /> ApPlica6ie rmll Nurnberg: <br /> 3Tt»RICYCLE til This iv a Through Shipment <br /> " TRANSPORT 'p[p, A ylii0m5MdQel waste as desc <br /> Prini/type Name i�✓ / slgnatur • <br /> Data <br /> 5 INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: p [: <br /> Z12 <br /> App4gble Permtl Nu berg: <br /> INTERMEDIATE HANDLER ITRANSPORTER CERTIFICATION:Recefpl of medical waste as(losajbw above. <br /> Priny/type Marne signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: PtrOnB R; <br /> Applicable faermit NNmbere: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. i <br /> PrInIfType Name Signature Dale <br /> 7.DISCREPANCY INDICATION 11 i , <br /> np Transferred i Q containers, 3 CU It to : Notch Salt lake, UT <br /> O 8A DenlpnAted FecaYtT: .Alta wle Facliiiy, BC.Attema"Fsclufy e0.Alternm Faol1hr. <br /> v 5T MCYCl„E.INC. STERICYCLE.INC. SMRICYCLE,INC. STERICYCLE,INC. <br /> LL <br /> A1345 Daoltttle Drive.Suite C 4135 W.Sw t Avenue 90 Noah 1100 West 1612 Starr Dr <br /> Z San Leandro.CA 64577 Fresno.CA 93722 North yah lake,LIT 84054 Yuba Cky.CA 95891 <br /> Lu (310)582- 1781 (569.1275-0894 (801)936. 1555 '(53Q)755-0585 <br /> dTS3.ti. SlO,9-25 3 f I T osT 22 DAL WHO qlEr%�111"ir tar P-g,P-115 <br /> AUTOCLAVe^D <br /> TREATMENT FACILITY.I certify that I have been authorized by the applicable slate agency to accept untreated medical wastes and that I have <br /> ►- recelved the above indicated wastes in accordance vWth the rogWrement MA �� <br /> outlined n su ation. - <br /> Print,W*Name- Signawro Date <br /> �U43- <br />