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<br />040 Sierlcycle , IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-234-0051
<br />1. Generator's Name, Address and Tele ne Number
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #j
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />UN 3291, PG II
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />UN 3291, PG II
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />UN 3291, PG II
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in proper condition for transport according to applicable international and national governmental regulations."
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<br />3. -Date ' •••
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone,#:
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<br />Applicable Permit Numbers:
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<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as descri ed above '
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<br />Date
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />Phone #:
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<br />Permit Numbers:
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<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />PrintlType Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
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<br />® 8A. Designated Facility: 8B. Alternate Facility: -8f Alternate Facility: 8D. Alternate Facility:
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<br />8E. Alternate Facility:
<br />Alatoclavable Treatment Autoclavable Treatment Treatment Incineration Treatment
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<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />90 North 1100 West
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<br />2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue
<br />North Salt Lake, UT
<br />84054
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<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 (801) 936-1555
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<br />(323) 362-3000 (510) 562-1781 (559) 275-0994LLJ Class V Incineration
<br />MTF Permit # P-115 MWTF Permit # TS -31 MWTS/OST Permit #TS/OST-22 Permit #91-02
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<br />Permit # P-6 MWTS Permit # TS/OST-25 Treatment by incineration
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<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />Date
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