|
MEDICAL WASTE�I3AC(�(A(G FORM NUY`
<br /> i SteriCy[le' SASE OF EMERGENCY CONTACT:CHEMTREC 1.800-424-93 STANDARD L"NIFEST00i-W-orrS D
<br /> CUSTOMER NO.21132 \
<br /> - t+� .•+ n.. _ wr_ n t t n S.Y ri ,�'!1 R T T 1�t7
<br /> I,.Generator's Name,Address and Telephone Number - - -- \
<br /> kTTH: Gayle Moale ISI �i l[ Ill f i l til �i l f l�� it
<br /> BIOlLODI ME14ORIAL NEST CAMPUS
<br /> 600 SOUTH LOWER SACRAMENTO ROD
<br /> LODI, CA 95242
<br /> Cu5ro in NuuaFR I;c n Al q n17 7_(1 11 Q GEN>RATOfre ReGMR,cnoN o
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINERTYPE 2C.NO.OF 2D. VOLUME
<br /> UN3291,Regulated Medical Waste,mms,, CONTAINERS
<br /> 62.PGII DOT-SP t3S56 RR65 - Sia; stem: Shnxp5 Tren:. Caxt 59 cu ft Cu Ft.
<br /> 11143291,Regulated Medical Waste,mos..
<br /> 6.2,Mil ITTZ - Bi03V=tams1TranzPort Box (4.2 au ft) �. 1d Cu FI. !
<br /> CC UN3291,Regulated Medical Waste,ri.o.s.,
<br /> 6.2,PGII Cu Ft, f
<br /> QUN3291,Regulaled Medlul Waste,n.o.s.,
<br /> IC 62,PGII Cu Ft
<br /> ILI UN329f,Regulated Medical Waste,n.o.s.,
<br /> Z 6.2 ,PGII Cu Ft.
<br /> (7 UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2.PGII Cu Ft.
<br /> UN3291Regulated Medical Waste,n,o.s„
<br /> 6.2,PGII Cu Fl.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII Cu Ft.
<br /> XB Cu Fr
<br /> 3.Generator's Certification:'I hereby declare that the contents of this consignment are fully and accurately TOTALS ► Gu Fs.
<br /> described above by the proper shipping name,and are classified,packaged•marked and labelled/placarded,and
<br /> are in all respects in proper c dilion for transport accord to applicable internatlonal and national governor ntal regulations.'
<br /> X!Printed/Typed Name 5ignalure Dato�
<br /> 4.TRANSPORTER 1 ADDRESS: Phone#:
<br /> F- Applale Aermi s F
<br /> WE
<br /> . y ¢ �t�umbers:-'-
<br /> 11875 White Rovh Rd
<br /> to 3TER)CYC1rE 3C Thiti i_ a Through 3h; •menu
<br /> a a TRANSPORT p F, T3Od' ¢fpr waste es described a.
<br /> �u. 5 _ � 3 f
<br /> ~ Print/Type Name Signature Dase /
<br /> 5.INTERMEDIAT OL R 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> Applicable Permit Numbers:
<br /> LalI me INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PdntfType Name Signature Oate
<br /> t.,w S.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone R:
<br /> i
<br /> S Applicable Permit Numbers:
<br /> l Rs' INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receiptof medical waste as described above.
<br /> PrintfTypo Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Tr r ferrad n in r cu R to : North Sal', lake_. UT
<br /> ❑BA.Designated Faculty: BB.Alternate Facility: LiBC,Altamaw Faclllty BD.Alternate Faculty:
<br /> v STERICYCLE.INC. STERICYCLE.INC, STERICYCL"INC. STERICYCLE,INC.
<br /> 134E nrtntmte(lava Suitor -a '1
<br /> 4135 W.S`niftAvenue 80 Nar?h 1 tr3Q W_st 161�Starr Or
<br /> Z San I aanrirn(A Q4.77 Fraarn C A A:t777 North Salt Lake,UT 8'4054 Yuba City,CA 95991
<br /> LU (5101 562-1731 (559)275-0994 (891)233- 1555 (530)755-0585 .
<br /> T,Ai TSffiISTQ5E CRnZ TSfOST 22 Classy Incineration Pemnitft 9t P-6,F-1 15
<br /> a AUTOCiAVED
<br /> W TREATMENT,FACILITY:I Certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> HP4 received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Prinl/Typs Name Signature Date
<br /> 57
<br /> 0004G
<br /> ORIGINAL
<br />
|