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1k A LP/ i rme <br /> 055/2$5/20 11 Inlay-G9-61111 (WE0J 15: 35 <br /> 20WED 15:44 FAX ODD5/049 <br /> 5terltyt ie' IN CASE OF EMERGENCY CONTACT:CHEMTREC 14W424-3w STANt7V1R.0 MwANIPM oor•so-WSM <br /> Route #: 913 -11 CuStoT9St*n?WA9i�2 MDRCOOAPOD <br /> I Generator's Name,Address and Tetephone Number <br /> MR: Gsdle Mases <br /> BIO/LODI MEMORIAL HOSPITAL <br /> 575 SOUTH F'AIRMONT DRIVE <br /> LODI, CA 95240 <br /> (209) 334--3411 4/15/2011 <br /> Cam N R t r+prra RcarsrnnnoH e <br /> 2A.DESCRIPTION OP WASTE re� COHTAINEAl1rPE <br /> urnsUN3293 Atgutatee MS�II nn nn��.. i<C, Na OF 2D. trpW1AE <br /> , �e.rr-w4'ay6 >r�tGS - Bia$ Leas S CONTAINERS <br /> ys harps Tzatss Cart (58 cu ft) Ft <br /> aN329t,Rey opted Medlwl wute n,dsCu <br /> 62.Pot1 1CtBF - BiaByztems Transport Bost (i.3 au ft) <br /> Ut1329t Regulated IVledipf waste,0A3.. Cu Ft <br /> 6.2.PGIi <br /> OQ 1JN329t Requisled Me6tral Waste,a,0.s., Cu FI <br /> � ss,Poli <br /> at RequfateG atedkal waste.a o s., Cu Fl <br /> trfi329t.Requtated Medical wase,n os,. Cub <br /> 6.2,P611 <br /> tlN329t.Regtdated Mt""M'fl-t"s Cu Ft <br /> 6,2,POq <br /> UM3291.Regu�tetl 6tedkaf waste,rAos., CH FI <br /> 6.2,PGH <br /> RxB1Cu Ft <br /> IZF3.z <br /> a3,Gertafetor's Certification:It hereby dedara that the contents of ihfs consignment are fogy and arcuratety TOTALS► Z.0 <br /> es In bled above by lite Proper shipping ,ane ane eSasstOad,pac$wged,marked and labe9edlptaeetded,and Cu R <br /> t respeds in Proper co tion for Iranspori among applkable inlernatbnal and rational goverrtm dal reputatioru' <br /> IName Signature nae <br /> 4.TRANSPNSP ORTERIADDRES <br /> '`913995 - 5506 <br /> 11515 White Rock Rei � tae Hvmbaw. <br /> ST£R <br /> RTE1CYCL£ X Thies is a Through Shipment <br /> TRANSPO �g 0 dkW waste as desaW above. <br /> ar <br /> PrhVtype Nament= Signature <br /> 5 INTERINEDIATE HANDMA 217 SPORTER 2 ADDRESS <br /> N Phone 8: <br /> Applkabla Peardt Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERnFICATION:Reew of meeicaf waste as desalted above. <br /> PIfnVType Name Signature <br /> Date <br /> `ro S.INTERMEDIATE HANDLER 3l TRANSPORTER 3 ADDRESS; <br /> � PtcOne I; <br /> Applkable Permit Numbers: <br /> i INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Reoe7pi of medic8l waste as described above. <br /> z <br /> PrtntiType Name Signature <br /> r.DI8CREPANCY INDICATION fi Date <br /> Transferred /l V Containers. cu ft to: North Salt false. UT <br /> jp 0 6A.DeHgnatad Faci[ay; 88.Attemaea FaClilly 8C.Attameh FaGtt <br /> 58 aD.Atremata Fadllty: <br /> STERICYCLE.INC. STERICYCL .INC, STERICYCLE,INC. STERICYCL.Lc,INC. <br /> LL 1345 a aDl ro IA 94 Store C 4135 W.Swift Avenue 90 North 1100 West 1612.Starr Dr <br /> San Leandro CA 8457 ��i Fresno.CA 93722 North Salt Lake,IIT 84054 Yuba C' ,CA 9599f <br /> w (5101502- 178f <br /> T531, E0 T�SIUST 22ag� (80 11 936- 1555 {530)755-0585 <br /> u�IAVED <br /> Class V Incineration Paor~mliw 91 P-O.P-115 <br /> ¢ TREATMENT FACILITY:4,certify that 1 have been authorized by the P 1 State Nen To t ntr� <br /> f- received the above-indicated wastes in accordance with the requirement outlined in that allthOrizat�lon. untreated medical wastes and that I have <br /> PrinVrype Name &{gnetureAPR 2,7. 2011 Date <br />