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<br />IN CASE OF EMERGENCY CONTACT: CHEINITREC 1-800-234-0051
<br />1. Generator's Name, Address and TelleWne Number
<br />L I
<br />X --
<br />CUSTOMER NUMBER
<br />2A. DESCRIPTION OF WASTE :2B. CONTAINER TYPE
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,! �-,nV ;X, C:.�-AJL
<br />LIN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, -J
<br />GENERATOR'S REGISTRATION #
<br />LIN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, i ^A A
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, :,u TEI�P-Jzac- C%;.
<br />LIN 3291. PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, 'g ;J
<br />tt"
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.os.,6.2,
<br />LIN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTAI
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects iry.proper condition for transport according to applicable international and nationa 9vernmental regulation!
<br />X Printed/Ty ped Name
<br />Signature
<br />4. TRANSPORTER I
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<br />0
<br />(L Z TRANSPORTER CERTIFICATION: Receipt of medical waste as descn06d,ebove,
<br />Print/Type Name Signature
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
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<br />W
<br />-j
<br />a. Z
<br />MW
<br />,wj INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />SERVICE RECEIPT
<br />ACCOUNT 11: 6070300-001
<br />CUSTOMER NAMESutter Gould/Stu,:I, to„ Me
<br />SERVICE DATE: 03107107 01:49-0) PM
<br />DRIVER 10: BSi
<br />---------------
<br />SHIPPING DOCUMENT #: MDFR004V3I
<br />---------------
<br />TOTAL CONTAINERS COLLECTED: 6
<br />TOTAL VOLUME COLLECTED: 35,4 CU FT
<br />--- ----------
<br />(.)iIA006U TO 14 0OA006T T814 0041t)6P TO!,`
<br />00A0060 TO 14 0OA006R T1314 00A007C TOi
<br />.4
<br />----- ---------
<br />VOL
<br />SUMMARY(By ContType) QTY CF
<br />TB14 44 Gal Tub(Bio), 6 35.4
<br />-------- -
<br />-------
<br />DELIVERY DOCUMENT It: PDFR00031
<br />--------- --- - ---
<br />TOrAL DELIVERED ITEMS: 6
<br />ITEM QTY
<br />T814 44 Gal Tub(Elio), C 6
<br />Date
<br />Phone
<br />Applicable Permit Numbers:
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
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<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #: i
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />ICU ft io
<br />J 1.- .6 :5
<br />❑ 8A. Designated Facility:
<br />F-1 8B. Alternate Facility: 8C. Alternate Facility:
<br />D 8D. Alternate Facility: 8E. Alternate. Facility:
<br />E
<br />Autoclavable Treatment
<br />Autoclavable Treatment Autoclavable Treatment
<br />Incineration Treatment
<br />Stericycle, Inc.
<br />Stericycle, Inc. Stericycle, Inc.
<br />Stericycle, Inc.
<br />3
<br />2775 E. 26th Street
<br />1345 Doolittle Drive, Suite C 4135 W. Swift Avenue
<br />90 North 1100 West
<br />E
<br />Vernon, CA 90023
<br />San Leandro, CA 94577 Fresno, CA 93722
<br />North Salt Lake, LIT 84054
<br />(801) 936-1555
<br />Z E
<br />LLI :-f
<br />(323) 362-3000
<br />(510) 562-1781 (559) 275-0994
<br />Class V Incineration
<br />P.
<br />MWTIF Permit # P-115
<br />MWTF Permit # TS -31 MWTS/OST Permit # TS/OST-22
<br />Permit #91-02
<br />MWTS Permit # P-6
<br />MWTS Permit # TS/OST-25
<br />Treatment by incineration
<br />LLI o%45
<br />TREATMENT FACILITY., I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />W 46
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<br />received the above indicated
<br />wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name
<br />Signature
<br />Date
<br />LEAVE AT GENERATOR
<br />
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