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<br />4.10,90 Stericycle, IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-234-0051
<br />------- ----
<br />SERVICE RECEIPT
<br />1. Generator's Name, Address and Tele one Number )"4-1 -----
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<br />IN ME
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<br />V4 ACCOUNT It: 6070300
<br />CUSTOMER NAMLSUTTER GOULDISIOCKIL
<br />7 SERVICE DATE 03121107 09:41:00 AM
<br />DRIVER ID: OS1
<br />SHIPPING DOCUMENT It: MDFR004X6M
<br />-------------
<br />7,
<br />TOTAL CONTAINERS COLLECTff 5
<br />-1—Tvi): 29 5 CLI FT
<br />CUSTOMER NUMBER
<br />GENERATOR'S REGISTRATION #
<br />TOTAL VOLUME
<br />--------------
<br />0OA0077 T814 0OA0074 TB14 040015 T314
<br />LEAVE AT GENERATOR qi,'
<br />2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE OOAOO(b ItIl'I
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />UN 3291, PG 11
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, u SUMMARY(By ContTy pe)
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, T814 44 Gal LOW, 5 29.5
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<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6,2, —17 7 7�7 Z t 7 ----- PDFRO006M
<br />DOCUMENT
<br />LIN 3291, PG 11 DEL I VERY
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, 3, Z, V A
<br />DELIVERED ITEMS: 3
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<br />UN 3291, PG 11 TOTAL
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, T-� S 42 0 sz a1 -a ii,: h rv,.-j QTY
<br />UN 3291, PG 11 ITEM
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2, T857 go Gal Tub(Bio)ET
<br />LIN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6,2,
<br />LIN 3291, PG 11
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 110 -
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and Tt:hl) OPP
<br />are in all respects in proper condition for transport according to applicable international and national governmental regulations."
<br />XPrinted/Typed
<br />Name Signature ,Date
<br />4. TRANSPORTER 1 ADDRESS- Phone #: -77
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<br />-4C Ave. Applicable Permit Numbers:
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<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above !1
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<br />Print/Type Name, Signature Date
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<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone #:
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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 Date
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<br />6. INTERMEDIATE HANDLER 3 TRANSPORTER 3 ADDRESS: Phone #:
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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 Date
<br />7. DISCREPANCY INDICATION su IN Vo
<br />SA. Designated Facility: ❑ 813. Alternate Facility:1�8C. Alternate Facility:8D. Alternate Facility: 0 8E. Alternate Facility:
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<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />U. 82775
<br />E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />F-
<br />North Salt Lake, LIT 84054
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722
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<br />LLI E:.!
<br />(801) 936-1555
<br />(323) 362-3000 (510) 562-1781 (559) 275-0994 Class V Incineration
<br />F2.
<br />MWTF Permit # P-115 MWTF Permit # TS -31 MWTS/OST Permit # TS/OST-22 Permit #91-02
<br />MWTS Permit # P-6 MVVTS Permit # TS/OST-25 Treatment by incineration
<br />LU ;TREATMENT
<br />MLNT 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 Date
<br />LEAVE AT GENERATOR qi,'
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