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nx uatt:/ t Ime MAY-L5-2UI1 (WED) 15: 35 p OU6 <br /> 05/25/2011 WED 15:44 FAX 006/0496 <br /> 4100 Ster# de' YWWtgqW <br /> � � S Foot•soassro <br /> UUMMER NO.21132 <br /> 1.Generator's MarneA,}ddress and Telephone Number j <br /> BIO/LORI MEMORIAL HOSPITAL <br /> 975 SOU'T'H FAIRMONT DRIVE <br /> LODI. CA 95240 <br /> (209) 334-3411 4/6!2011 <br /> Cugfoom Nuum 6089077—OOZ aomm="RWMWMep$ <br /> 2A.VESMUPTION OF WASTE 28. COMAlNSR TYPE <br /> UNMI RepubW 2C. TA OF 2D. VOLUtlE <br /> 61 PGII �144�¢t0.3�. P.RSS - UaSystews Sharps Tlrarss Gant (59 to ft) COHTAiNERS <br /> 329t. em <br /> szRepulatedMedxalWaste.nos } }gg - Bi03V5ts Tran=som Box (4.3 au ft) F <br /> 62,Pal <br /> @ UN3291 RlOutatld lytlOk3l Wa41t Ro.a, Cu F <br /> FFp- 62,PG11 <br /> Q UN3291 Reoubw I4ledkal%GZn.o.e.. Cu F <br /> a: 82,PGli <br /> tZ UN P9t'il{t �qe�Me6�cal Ylast0.nos., Cu F <br /> C3 UN34r,Rlpatatod Atedkat WaStl.RAS., Cd F <br /> 0.2,PGII <br /> UR3291 Repbtittsrt Me?xa1 tNaSte.n,D.f Ctl F <br /> 6.3,PGI/ <br /> 6 2 PGll N3221Ro fated M win, n.o.i.. Cu F <br /> RSBI Cu F <br /> 3 t r mccq*w:r r hereby declare u+at the DoMents of mks consignment are suly end axuratDy TOTALS► j I Jf-f, <br /> ewfted above aY P pe name.and are cEasstlled,packaged,marked and tabelledlptaeataed.and Cu F <br /> are In all respects In proper oo lion for trensport a000rdmg 1 <br /> appticabta International and national Bove nla#regulations.' <br /> I Prbted(Typed Name SI nature4 DBte' r <br /> 4.TRANSPORTER t ADDRaak2)&�ESS: <br /> �I Phme(0316) 9t3S - 5506 <br /> Sr 11875 White Rome Rd ApplicAbie Pemvt Nun+bers: <br /> ZTERICYC1rE 'Phis ie a Through shipment <br /> aQ TRANSPQRTEA%veftn Wage as described <br /> 7 PrIntJlyype Name Stpnarure Date <br /> 6 INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone a: <br /> ry <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of modlow waste as dosaibed above. <br /> Pdntrrype Name Signature Date <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 0. <br /> � Applicable Permil Nwnbom <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION.Receipt of medtca#waste as described above. <br /> Pdnveype Name Slpnalurs pate <br /> 7.DISCREPANCY INDICATION <br /> Transferred 1 C� <br /> eontainers,duk CU R to . North Salt lake,UT <br /> ❑$A.Etesignaled Foatity: $6.Aftarn to Fecluty AnAn.-ma FedRly: $0.Aftnra a Fadtpy: <br /> STERICYCLE.INC, STERICYCLE,INC. STERICYCLE,INC. STERI CYCLE,INC. <br /> 11 1 1345 poolitde t3rl+re.Suite C 4135 W.SwfftAvgnue 8Q Noah 1100 West 1 TE Starr L . <br /> Sart L.eandro.CA 84577 Fresno.CA 93722 NoM Walt Lake UT 840,6,4 Yuba C ,CA 95$81 <br /> E (510)562- 1781 (559/275-Q894 ' <br /> W ��ST25 fool)838- 1555 (530)755-0585 <br /> ORM TSf4ST 22 Class V tfr ,ne tion Pemiitt#21 P-8,P-!t5 <br /> TREATMENT FACILITY:I cerilty that#have been authorized by the st� � �tfrltrTalAUTOCLAVED I tedlcxl wast n <br /> recelved the above Indicated wastes in accordance with the tequirernent ou ii Tn That au harization es and that#have <br /> PAWType Nantes -- Signature <br /> *a.u.tr.+clfry Date — --- <br /> (00204 7 <br />