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eve Stericycle' I d 1( SIM IGeMICONTAf-SCHEMTRECI-8DD-424-9300 STANDARQ_ffljQe1j-ggOCA
<br />CUSTOMER NO. 21132
<br />�Y1�J (J�Jr j 'j
<br />b TREATMENT LI Y: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the aiir>�ir�l26�astes In accordance with the requirement outlined In that authorization.
<br />Printflype Name
<br />TYamchrnd contaln�rs,
<br />Date
<br />oU 2 to : N. Sek Lake, UT
<br />1. Generator's Name, Address anti Y6I4plforio Number
<br />atis; � t I�IIt II
<br />1111111111111111AT-WM
<br />SGNF STOCKTON MEDICAL PLAZA 1
<br />2505 W HARMER LN
<br />STOCKTON, CA 95209- 2839
<br />(209) 422-7578 8/24/2021
<br />CUSTOMER NUMBER 6131468-001 GENERATOR'S REGISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />20. CONTAINERTYPE
<br />20. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n,o,s.,
<br />6.2, PGII
<br />TBO4 - 28 Gal Tub (Bb) (3.7 CU 2)
<br />CONTAINERS
<br />Cu F
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />T849 -37 Get (
<br />6.2.PG11
<br />Cu
<br />r
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TB14 -44 Gal Tub(1110) (5.9 CU A)
<br />6.2, 1`1311
<br />Cu F
<br />Q
<br />r
<br />UN3291 i1 Regulated Medical Waste, n.os.'
<br />LICUr 1)
<br />Cu F
<br />11
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />Z
<br />6.2, PGII
<br />Cu F
<br />6.2, PGII Regulated Medical Waste, n.o.s.,
<br />434---Y C43-(____..,) Gal TUX5.7CU
<br />Cu F
<br />6231`011 Regulated Medical Waste, n.o.s.,
<br />KR_ - ftsydom CArliftwd Boot (4.3 CU A)
<br />Cu F
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />6.2, P011
<br />Cu F
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu F
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 10, S Cu F
<br />described above b the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all roper loq for transport according to applicable International and nallo overnmental regulation
<br />Pdnf—1 Neignatur
<br />�
<br />4. TR SPORTER 1 SS. Phone 1!:
<br />!a M Inc.Ino. ❑ This rough 3hipmanl
<br />, Permit
<br />4135 YY. SW to o AppilcabiH aular R/bgO3400
<br />c
<br />Fmsno,CA93722
<br />:y
<br />:
<br />TRANSPORTE Receipt of medical waste as describe ove.
<br />RTIFICAJ[Qtj'
<br />PrInMpe Name E&daoSignature Date J
<br />5. INTERMEDIATE HANDL R 2 / T ANSPORTER 2 ADDRESS: Phone N:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />PrinVlype Name Signature Date
<br />6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone N:
<br />Applicable Permit Numbers;
<br />z
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrInVType Name Signature Dale
<br />7. DISCREPANCY INDICATION
<br />Alternate Facility:
<br />Designated Facility:
<br />e9, Alternate Facility:
<br />8C. Att,mats Facility:
<br />8D,
<br />0b dcycIs, Inc. (Auboclsve)
<br />Sterlcycle, Inc.I(ncinanioir)
<br />Sterlcycle, Inc. (Autoclave)
<br />Coverts Madon, Inc
<br />135 W 904M AV$
<br />90 N, Foxboro OM
<br />1651 Shall DrNs
<br />4850 Brooldak* Road NE
<br />Fresno, CA 93722
<br />North Salt Lake, UT 84054
<br />HOUlder, CA 56023
<br />Brooks, OR 97305
<br />(866)783.7422
<br />(804)936-1171
<br />(966)783-7422
<br />(505)383-0890
<br />i
<br />TS/08T-22
<br />3A-448/JA-36
<br />TS/09T=83
<br />Pemnit# 364
<br />DAL(FANNE ORTIZ
<br />i
<br />AUTCCfAVEI)
<br />b TREATMENT LI Y: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the aiir>�ir�l26�astes In accordance with the requirement outlined In that authorization.
<br />Printflype Name
<br />TYamchrnd contaln�rs,
<br />Date
<br />oU 2 to : N. Sek Lake, UT
<br />
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