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Wi �� Stericyc�e IN CASE OF EMERGENCY CONTACT: CHEMTREC 1800-424-9300 oinnunnu MNivirwi uuova-a: •ivuun
<br />ROltte #f: 123 — 16 CUSTOMER NO. 21132 MQ RQQP6RJ
<br />i r_`ewers f^rfa Nemo AAA an and Talanhrina rllrlrnhar
<br />Transferred _ containers, _ cu Ito : 8moks, OR
<br />Transferred _ containers, eu A to : N. Saft Lake, UT
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<br />ATTN:Maria III IIIIIII�IIIIIII
<br />II l l II ��l�ll�l������� ��� 1 I
<br />SGMF STOCKTON MEDICAL PLAZA 1
<br />2505 W HA1vMvER LN
<br />STOCKTON, CA 95209- 2839
<br />0 422J578
<br />8117/2021
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION 0
<br />2A• DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />21), VOLUME
<br />UN3291 Regulated Medical Watte, n•o.s.,
<br />6.2, PGII
<br />CONTAINERS
<br />Cu I
<br />UN3291
<br />62, GII Regulated Medical Waste, n.os.,
<br />T849 - 37 Gal Tub 81a 4.9 cu
<br />Cu
<br />X
<br />6 2329111 Regulated Medical Waste, n,o.s.,
<br />TB 14 -44 Q al TO Blo 5.9 cu R
<br />c�
<br />Q �UN3291
<br />21Regulated Medical Waste, n•os,
<br />, PG1I
<br />T821-__ YTP15{ )f Y154-,�—_)20 pal Tub(2.7CUFT
<br />Cul
<br />W
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />Z
<br />6.2, PGII
<br />Cu I
<br />Lj
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
<br />F
<br />a Cu I
<br />UN3291 Regulated Medlcal Waste, n.o,s„
<br />6.2, PGII
<br />CU I
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
<br />Cu I
<br />UN3291 Regulated Medical Waste, n•o.s•,
<br />6.2, PGII
<br />Cu 1
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ►
<br />Cu I
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are In all res oper c iti n for transport according to applicable International and nation ern tai regulations:'
<br />1
<br />r
<br />P nt am N
<br />4, TRAN RTER 1 RESS;
<br />Dat
<br />Phone u: 6)783-7422
<br />Stericycle, Inc. ❑ This Is a Through Shipment
<br />Appllcable Permit Numbers:
<br />.
<br />R
<br />4135 W. Swift Awe
<br />Hauler Reg# 3400
<br />e1
<br />Fnesno,CA93722
<br />t
<br />QQ
<br />TRANSPORTE ERYIFICATIO:Receipt of medical waste as des d a v
<br />~
<br />PrinMpe Name Signature
<br />Dale
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone N:
<br />,
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Dale
<br />e. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone N;
<br />a
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Data
<br />7. DISCREPANCY INDICATION
<br />A. Daaianaled Facllttyr 8A. Alternate Facillty: 8C. Atternate Facility:
<br />E2 817. Altemate Facil(ty:
<br />Sterlcycle, Inc. (Autocinve) Stericycle, Inc, (Indnerator) Stericycle, Inc. (Autoclave)
<br />417 9Q N. FOXbOrO
<br />Covanta Marion, Inc
<br />y
<br />rMYi 1&51 Sholtan QrtvA
<br />FW Z kiarN, oat! Laka, UT 4405.4 Riatllt#dr, CA 66023
<br />412150 RrAoWxkA Rand MW
<br />arocko, OR a7300
<br />j
<br />ttStilf) {t30i)5aE-117i (b86)T83-7477
<br />7SIC T 2. 2x21 3A-4481JA-36 TS10ST 83
<br />(545)353-416515
<br />Permit * 352
<br />TREATMEN fi�tt; I certify that I have been auAorized by the applicable state agency to accept untreated medical wastes and that I have
<br />&ted
<br />received the above wastes in accordance with the requirement outlined In that authorization,
<br />PdnVType Name Signature
<br />Date
<br />Transferred _ containers, _ cu Ito : 8moks, OR
<br />Transferred _ containers, eu A to : N. Saft Lake, UT
<br />r%r3Ir1f1'f Al
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