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--1 LA IiLiiC <br />HAI-A10US MATERIAL, SHIPPING IJOUNLN! <br />TRANSPORIER:Sle, <br />icycle, Inc. <br />4135 West Swift Ave. <br />Fresno Ca 93722 <br />(559) 275 0994 <br />116114 FMLIIGLNCY PHONE ! <br />GENERATOR ACi:oUNT n. 60/ <br />Sutter Gould North Cal if Pt <br />2505 W Hammer Lane <br />Stockton CA 95209 <br />('209) 944-4360 <br />i <br />SERVICE DAII 10?25106 10 15: 00 AM <br />I <br />SHII,PING DOCUMENT 0: MUFRO04006 <br />AoI! MtUICAL WASTE 6.2, LIN 'I'! <br />TOTAL CONTAINERS COLLFCIEU 4 <br />TOTAL VOLUME COLLECTED: 23 6 CO FI <br />VOL <br />SUMMAR'YlBy Cont?ype) QTY CF <br />I1314 44 Gal Tub(Blo), 4 23 6 <br />N!�liui!� TB 11 OOAOOIA T814 <br />00011 T814 <br />I J,; I:;re that the soul, -i , <br />';) title! 1, ale fully and aa:,, <br />II <br />by the proper I <br />-lassified, pa<r � , <br />did 141&1 k:r!placarded, and Orr in A!: <br />Loper condition i, l <br />,,,•;,, y I,,<pplirahla intei—i <br />,J <br />�� national guvenunental regulations. <br />MEDICAL WASTE TRACKING FORM NUMBER <br />I#SE OF EMERGENCY CONTACT: CHEMTREC 1-800-234-00 <br />d Telephone Number <br />t ; ,. w1<10 <br />S!' <br />j <br />GENERATOR'S REGISTRATION # <br />CONTAINER TYPE 2C. NO. OF 2D. VOLUME <br />CONTAINERS <br />Cu F <br />dPI Cu <br />Cu F <br />Cu F <br />Cu F <br />Cu F <br />Cu F <br />Cu F <br />Cu F <br />Iclare that the contents of this consignment are fully and accurately TOTALS ® Cu F <br />me, and are classified, packaged,' marked and labelled/placarded, and <br />insport according to applicable international and national governmental regulations <br />Signature 3 ; Date <br />Phone #: <br />�skaa <br />a <br />GENERATOR AGENT t,' I NAMi <br />Receipt of medical waste ash cribetl a ve. , <br />X <br />## <br />Signator �`' Date R <br />`AUTHO RIZED S GNATI�E <br />2 ADDRESS: Phone #: <br />', <br />ITER <br />Applicable Permit Numbers: <br />DRI E :' I Ben <br />MPORTER CERTIFICATION: Receipt of medical waste as described above. <br />X <br />Signature Date <br />OH NER SIGNATUREI <br />TER 3 ADDRESS: Phone #: <br />Applicable Permit Numbers:` <br />WASIE iRANSILR DATE:0. <br />0-` <br />_ THIS IS A THROOGII SHIPANT. <br />ISPORTER CERTIFICATION: Receipt of medical waste as described above. <br />zr <br />DESIINATION FACILITY:Signature` <br />Date <br />IZA: 2SIFRICYCtE INC - FR'SNO, CA <br />! <br />S0,1C CLE INC - KRTH SALT L, LII <br />S IFH I I YE.I E INC SAN LEANURO CA <br />ternate Facility: <br />8C. Alternate Facility: <br />8D. Alternate Facility: <br />8E. Alternate Facility: <br />STERICYCLE INC I)ERNON CA <br />Navable Treatment <br />Autoclavable Treatment <br />Incineration Treatment <br />V <br />Q <br />OAIE OF RECEIPT AT l�� 2< <br />J <br />6ycle, Inc. <br />[Doolittle Drive, Suite C <br />Stericycle, Inc. <br />4135 W. Swift Avenue <br />Stericycle, Inc. <br />90 North 1100 WestNorth <br />U. <br />TREATMENT FACILITY: ,' l _1 <br />eandro, CA 94577 <br />Fresno, CA 93722 <br />Salt Lake, UT 84054 <br />�. <br />W <br />DFl IVEriY DOCUMENT 1. PUFR004hnB <br />562-1751 <br />(559) 275-0994 <br />(801) 936-1555 <br />Class V Incineration <br />FPermit #TS-31 <br />MWTS/OST Permit#TS/OST-22 <br />Permit #91-02 <br />L <br />TOTAL DELIVERED !' <br />�S Permit#TS/OST-25 <br />Treatment by incineration <br />W <br />[.have been authorized by the applicable state agency to accept untreated medical' wastes and that I have <br />ITEM <br />accordance with the requirement outlined in that authorization. <br />TBA 44 Gal TuboJwl _ 4 <br />Signature Date <br />