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IN CASE OF ENIERGENCY,CONTACT. CHEMTREC 1-800-234-0051
<br />LEAVE AT GENERATOR
<br />W4kj
<br />(55q
<br />h6. Dou -00 1
<br />'�ttpr Gould North Cali[ Peds
<br />-,05 W Haiiiiiier Lane
<br />Stockton CA 96209
<br />(209) 944-4360
<br />�a,V I CE DAII E 11 iO 1 /06 Oe' (15:011 PM
<br />SHIPPING DOCUMENT 0 MOFIROO&I , 14
<br />MI-MCAL WASTE 6,2, 11,13AJI, Klil
<br />TUIAL CONTAINERS COLLECTED ! 4
<br />IOIAL VOLUME COLLECTED: 23.G LU FI
<br />VOL
<br />N(By
<br />"UMMAP L -
<br />S tType) QTY -F
<br />TB14 44 Gal Tub(Bio) 4 2i 6
<br />lc; XM TB,!I 0OA001i TB14 I)uAt:1 I
<br />fj�A(",015 Tald
<br />;1,, re that the cwt -I.,
<br />mens aid fully alit; J, l
<br />11Wd i'O—e by the propel
<br />mal ,, � C 12 SS; f I ed Pk%f
<br />and lal)el Iftllj.11acardetl aflil
<br />II
<br />C,Ijek t i-Olidilion iu; 1-1-pwt
<br />applicable inter _"al ",d
<br />wt iLoulations
<br />GENERATOR AGENT PRINT NAME
<br />K
<br />AUTHUHiZEU SIL11ANK
<br />DRIVER. Salcido, Ben
<br />x
<br />DRIVER SIGNATURE
<br />WAS[t: IRANSFER DATE:
<br />J_JTHIS IS A I'HROUtill SHIPMENT.
<br />OF"'I INAT [ON FACILITY:
<br />SIERICYCLE INC FRBNO, CA
<br />SIERICYC!-E INC NORTH i I "Al
<br />0 — UT
<br />SJFHICYCIE I N(SAN I '-AWRO, 1"A
<br />STERILYLI-1. INC VLRNON, CA
<br />GATE
<br />ul: R1:CE.!IJT AT
<br />TRILAIMENi FrADLITY: J
<br />DFt 1 VERY UOLUMENT I POFR(1(4l11
<br />101AI, DELIVERED ITEMS: 4
<br />ITEM QTY
<br />1814 44 Gal Tub(Bio), C 4
<br />1. Generator's Name, Address and TeleplWne Number IV, 7 44
<br />" 71
<br />7
<br />�7 1,
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />T, 5,
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />L-13 4. 4 S
<br />0
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />7 tt 77t -7 t7 77
<br />UN 3291, PG 11
<br />Lu
<br />REGULATED MEDICAL WASTE, To.s., 6.2,
<br />Z
<br />UN 3291, PG 11
<br />UJI
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in proper condition for transport according to applicable international and national governmental regulations."
<br />Printed/Typed Name Signature
<br />4. TRANSPORTER 1 ADDRESS:
<br />LLI
<br />IX
<br />0
<br />-n 9 2
<br />9L
<br />U)
<br />CL Z
<br />TRANSPORTER CERTIFICATION:,keceipt of medical waste as described,above':,'
<br />$-7
<br /><
<br />Print/Type Name Signature
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
<br />LU
<br />01 LU 0-j
<br />0. Z
<br />Z0121
<br />INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />93
<br />Print/Type Name Signature
<br />6. INTERMEDIATE HANDLER 3 TRANSPORTER 3 ADDRESS:
<br />Uj
<br />LU
<br />0 2
<br />a.
<br />V)WZ
<br /><
<br />INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />7. DISCREPANCY INDICATION
<br />8B. Alternate Facility: Alternate Facility: 8D. Alternate Faciff1
<br />8A. Designated Facility: El 8C.
<br />❑ P
<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treats
<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />LL. N s
<br />2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 WE
<br />$Vernon,
<br />North Salt Lake, I.(801) 936-1555
<br />CA 90023 San Leandro, CA 94577 Fresno, CA 93722
<br />(323) 362-3000 (510) 562-1781 (559) 275-0994 Class V Incinerati,
<br />94.9
<br />MVVTF Permit # P-115 MVVTF Permit # TS -31 MVVTS/OST Permit # TS/OST-22 Permit #91-02
<br />MWTS Permit # P-6 MVVTS Permit # TS/OST-25 Treatment by incir
<br />LLJ At
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreatec
<br />IX a
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />LEAVE AT GENERATOR
<br />W4kj
<br />(55q
<br />h6. Dou -00 1
<br />'�ttpr Gould North Cali[ Peds
<br />-,05 W Haiiiiiier Lane
<br />Stockton CA 96209
<br />(209) 944-4360
<br />�a,V I CE DAII E 11 iO 1 /06 Oe' (15:011 PM
<br />SHIPPING DOCUMENT 0 MOFIROO&I , 14
<br />MI-MCAL WASTE 6,2, 11,13AJI, Klil
<br />TUIAL CONTAINERS COLLECTED ! 4
<br />IOIAL VOLUME COLLECTED: 23.G LU FI
<br />VOL
<br />N(By
<br />"UMMAP L -
<br />S tType) QTY -F
<br />TB14 44 Gal Tub(Bio) 4 2i 6
<br />lc; XM TB,!I 0OA001i TB14 I)uAt:1 I
<br />fj�A(",015 Tald
<br />;1,, re that the cwt -I.,
<br />mens aid fully alit; J, l
<br />11Wd i'O—e by the propel
<br />mal ,, � C 12 SS; f I ed Pk%f
<br />and lal)el Iftllj.11acardetl aflil
<br />II
<br />C,Ijek t i-Olidilion iu; 1-1-pwt
<br />applicable inter _"al ",d
<br />wt iLoulations
<br />GENERATOR AGENT PRINT NAME
<br />K
<br />AUTHUHiZEU SIL11ANK
<br />DRIVER. Salcido, Ben
<br />x
<br />DRIVER SIGNATURE
<br />WAS[t: IRANSFER DATE:
<br />J_JTHIS IS A I'HROUtill SHIPMENT.
<br />OF"'I INAT [ON FACILITY:
<br />SIERICYCLE INC FRBNO, CA
<br />SIERICYC!-E INC NORTH i I "Al
<br />0 — UT
<br />SJFHICYCIE I N(SAN I '-AWRO, 1"A
<br />STERILYLI-1. INC VLRNON, CA
<br />GATE
<br />ul: R1:CE.!IJT AT
<br />TRILAIMENi FrADLITY: J
<br />DFt 1 VERY UOLUMENT I POFR(1(4l11
<br />101AI, DELIVERED ITEMS: 4
<br />ITEM QTY
<br />1814 44 Gal Tub(Bio), C 4
<br />
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