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Rx Date/Time MAY-25-2011 (WED) 15: 35 p 008 ` <br /> r 05/25/2011 WED 15: 45 FAX 2008/049 <br /> tri• Stericycle, <br /> •� � .�oa IN CASE OF EMERGENCY CONTACT!CHEMTREC i•80D-4241380 5'r r�NrFES�OOi-tie-oB�Sifl <br /> Route #: 913 -0 Cu5t0=9TdkRW*&2 HPR -00-4 ~q2 <br /> 7.Generator's Name,Address and Telephone Number <br /> ATTR: Gavle Koses <br /> BIO/LODI MEMORIAL HOSPITAL, <br /> 975 SOUTH FAIRMONT DRIVE <br /> LODI. CA 55240 <br /> 209) 334-3411 3/18/2011 <br /> CLISMUER KINOtR Gt3efxaTaRs REtasrrurroa s <br /> 21L DESCRiviri0N OF WASTE 2e CONTAINER TYPE 2C.NO OF 20. VOLUME <br /> 6UUMI Replaw Medital Waste.n.os., COWTAWERS <br /> O'DT•SP 13SZ XRSS - SioS tetrrs Sharps Tra>:Ls Cart (59 Cu ft) � <br /> U2 Mil Rt9uhtW Medical Waste,a.os, ff. Co F <br /> WE - BioSvstems Transport Bos (4.3 au ft) cu <br /> ¢Q 6N Il Regulamed Medka!Waste.n e a <br /> a <br /> UMI Reg Ied Medial Waste,n o.S„ Cu F <br /> Q 62,IGIi <br /> W UN3294,Regafated Medical waste.aa.s„ Cu F <br /> 1Z fi2•Pull <br /> UN3 91 ReflWated li�edkal waste,n o s„ Cu F <br /> 62,>�ci1 <br /> UtCt281,Regulated Medical Waste,mos' F' <br /> 0.2,pol <br /> UlI Regulated MWW Waste,rtes.. F <br /> Cu F' <br /> RXR� , F <br /> 3.GsneraWeg CertVICatlon:9 hereby declare that the contents Or this Consignment aro fully end accurately TOTALS 0, <br /> esc .5-2 <br /> 32 <br /> described above by tate proper shhVkV namnd e.aare Classed.Packaged,martrod and fabelledowardad,and Cu F <br /> are In aA respects In preps► on for trerasporl acoorcling applkk aybie International end natlonat <br /> ' gave mel ufatkoms" <br /> r IFrintedrT edNaitie 5 taro Date r '� <br /> Q 4.TRANSPORTER t ADDRESS: PhoneIR ��tg':�61 <br /> npptic66>&"r�rmifrfu5rnbars:$506 <br /> 11875 White Rack Rd <br /> 3TCATCY'CLE [ This is a Through Shipment <br /> TRANSPORTS •fit to t nests ss described above. <br /> WWTyps Name &igneture Date /S��/ <br /> t>,iNTIwRMEDIATE HANDLER 2!TRANSPORTER 2 AOORESS: Phone t: <br /> w <br /> APpBcable Permit fltrrrr0era: <br /> INTERMEDIATE HANDLER/TRANSPORTER CEFMFI <br /> CATION: grt Recea1 medicsl waste as doscdbed alcove. <br /> Pr1nVType Nan're Signature Date <br /> 6.INTERMEDIATE HANDLER 3 f TRANSPORTER 9 ADDRESS: Phone Y. <br /> s¢ <br /> 8 Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of modlcal waste as dewribed above, <br /> r <br /> PdnVType Name Signature D <br /> ate <br /> 7.DISCREPANCY INDICATION r <br /> Tran d containers. I Ste, ftto : North Salt Iake. UT <br /> r ©SA Dodgnetsd FaCtiay 41JI) tt.Alteinela FaelllM 8C.Altoma%Fadltry: 80.Arternme Fsetf : <br /> STEPJCYCLE.ING. STERICYCLE.INC. STERICYCLE INC. STERICYCLE,INC. <br /> 1345 DooE•infe Drive.Suite C 4135 W.SWft Avenue Ra North 110016 est i8i 2 Starr Dr <br /> San Leandro.CA 94577 Fresno,CA 93722 North Sat Lake,LIT W54 Yuba C'tty,CA 95991 <br /> I5i Qj 562- 1791,!g ,.E c>T1z (559)275-W94 (80 i 1936- 1555 (WO)755-0585 <br /> CS3l.'1 StL75TZ8-, _� TV=22 cliass V llVcinesatton Falai 21 P-$"F-i 16 <br /> IxPit TREATMENT FACUT'Y:I Certify that I have been authorized by thea l � e EDrization.Ql TeZI medical wastes and that I have <br /> I— received the above indicated wastes in accordance with the requirement outlined In that aul <br /> Print/Type Name ",r f—. Signature Date <br /> - -----_ <br /> Boas 7 <br />