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i ® Stericycie' <br />®r r.,,..m,o wc,w. RO&W-, who, <br />�SE OFf,8aVf Nj j CT: Cy1"EC 1-800-234-0 1 Q4AflD.MBNIF,F*SI Qot to 06 STO <br />{ + 1311MATS: Caria Va11em/Project <br />1. Generator's Name Address and Telepphone Number 1111+IBM <br />I I III <br />l! <br />BIO/ST JOSS INWD CARE/OCCRLTR <br />° <br />1801 E. MARCS LANE BLDG 470D/480D <br />STOC1iTON, CA 95210 <br />(209) 467-6395 <br />4/22/2009 <br />6062804-003 <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION fi <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />20. VOLUME <br />REGULATED MEDI ftn.o.s.,6.2, <br />8S02/RS02 - 2 Gal Sherpa Reusable (0.3 cu ft) <br />CONTAINERS <br />UN 3291, PG II <br />Cu Ft. <br />REGULATED MEDIG4 SWgn.os.,6.2, <br />S1013- <br />UN 3291, PG II_ <br />Cu Ft. <br />p� <br />REGULATED MEDIC n.o.s.,6.2, <br />v a rp <br />0 <br />UN 3291, PG II <br />nalfrin=12 <br />Ft. <br />REGULATED MEDI W mos.,6.2, <br />—aepsCu <br />° <br />3291, PG II <br />Cu Ft. <br />WUN <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />T30Z - ° <br />UN 3291, PG It <br />Cu Ft. <br />tZ <br />0 <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />UN 3291, PG I! <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.o.s..6.2, <br />P -X Q j _ Q®x '� ,' <br />r <br />,t <br />! <br />2 <br />UN 3291, PG !I <br />t7 w `t k 1 <br />'1' • 3 <br />1 <br />a Cu Ft. <br />REGULATED MEDIC/bW%p.ojt52, <br />– ee RackCu t <br />UN 3291, PG II <br />Cu FL <br />Regulated Medical <br />KR - o systems Cart or Box ( cu ft) <br />*.3 <br />Cu Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTAL$ �' <br />/� <br />2.- G ° �O' Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and Iabelledlpiacarded, and <br />ition for transport according to applicable international and national govemmental regulations <br />are in all respects in proper condition " <br />k WT <br />1 <br />Z'2 <br />w� Printedlf ed Name ` ' S' nature <br />4. TRANSPORTERgt*RgS e, Inc. <br />PhoneIM #: <br />IV <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> medical waste s described above. <br />~ <br />�' �' <br />4 22 U <br />Print/Type Name '"^ "" r Signature <br />Y� <br />Date <br />S. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: <br />Phone #: <br />N <br />pC � <br />R <br />Applicable Permit Numbers; <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />u� <br />Applicable Permit Numbers: <br />HANDLER /TRANSPORTER CERTIFICATION: Receipt <br />INTERMEDIATE of medical waste as described above. <br />x <br />Printrlype Name Signature <br />Date <br />• <br />7. DISCREPANCY INDICATION � <br />Truilliftr iD dairh91'S, cu a to �a 4 C 4"°l 1 <br />8A. Deal Hated Faclll �. Alternate Faculty: 6C. Aitemate Facili <br />STER CYCLE INC ICYCLE INC STERICYCLE&C <br />80. Alternate Facility: <br />STERICYCIE INC <br />d <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />W <br />Jp t LSO <br />g <br />a <br />TREATMENT FACILITY: I thatfi eq An rized by the applicable state agency to accept untreated medical wastes and that t have <br />certify <br />H <br />received the above indicated wastes ��}} o((��alNic the requirement outlined in that authorization. <br />Print/Type Name Signature <br />Date <br />f•d A p fr~�. l0 OY ,I <br />