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<br />*a Stericycle, IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-234-0051 
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<br />i. Generator's Name, Address and Tel one Number 
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<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION # 
<br />2A. DESCRIPTION OF WASTE 
<br />2B. CONTAINER TYPE 
<br />2C. NO. OF 
<br />2D. VOLUME 
<br />REGULATED MEDICAL WASTE, ri.o.s., 6.2, 
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<br />UN 3291, PG 11 
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<br />3. Generator's Certification: hereby declare that the contents of this consignment are fully and accurately Cu F 
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and 
<br />are in all respects In condition for transport according to applicable international and nation lgQvernmental regulations." 
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<br />Printed/Typed Name' Signature Date 
<br />4. TRANSPORTER 1 ADDRESS: Phone #: 
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<br />Applicable Permit Numbers: 
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<br />TRANSPORTERZERTIFIC ION: Receipt of medical waste as described.a ove./ 
<br />Print/Type Name Signature Date 
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone #: 
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<br />INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #: 
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<br />INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. 
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<br />Print/Type Name Signature Date 
<br />7. DISCREPANCY INDICATION 
<br />k 
<br />8A. Designated Facility: 
<br />88. Alternate Facility: 
<br />r 
<br />Alternate Facility: 
<br />8D. Alternate Facility: 
<br />0 8E. Alternate Facility: 
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<br />Autoclavable Treatment 
<br />Autoclavable Treatment 
<br />Autoclavable Treatment 
<br />Treatment 
<br />Incineration Treatment 
<br />Stericycle, Inc. 
<br />Stericycle, Inc. 
<br />Stericycle, Inc. 
<br />Stericycle, Inc. 
<br />LL.! 3 
<br />2775 E. 26th Street 
<br />1345 Doolittle Drive, Suite C 
<br />4135 W. Swift Avenue 
<br />90 North 1100 West 
<br />2 
<br />Vernon, CA 90023 
<br />San Leandro, CA 94577 
<br />Fresno, CA 93722 
<br />North Salt Lake, UT 84054 
<br />Z N E 
<br />W 
<br />(323) 362-3000 
<br />(510)562 -1781 
<br />(559)275 -0994 
<br />(801) 936-1555 
<br />Class V Incineration 
<br />MWTF Permit # P-1 15 
<br />MWTF Permit # TS -31 
<br />MWTS/OST Permit # TS/OST-22 
<br />Permit #91-02 
<br />MWTS Permit # P -6 
<br />MWTS Permit # TS/OST-25 
<br />Treatment by incinerate 
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<br />I KhAl-M hNI FACILITY: I Certifv 
<br />that I have been authorized 
<br />by the armlicable state aaencv 
<br />to accept untreat 
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