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<br />ass Stericycle, IN CASE OF EMERGENCY CON A��: CHEMTREC 1-800-234-0051
<br />Ld 9 TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept ur
<br />a received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />11n1i[UN MATERiAI MIPPI , UUf'_IMENI
<br />1. Generator's Name, Address and TeIeM9ne Numberr
<br />TRANSPORTFR:Stericycle Inc.
<br />4135 West' wift Ave.
<br />Fresno, Ca 93722
<br />,., 5
<br />(559) 275-0994
<br />CUSTOMER NUMBER {_. w ._ ._. ._ ... _ ... .. GENERATOR'S REGISTRATION #
<br />?� HOUR FME;R( NCY PHONE: 1-8Uu rte ,u;,I
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />2505 W Hammer Lane
<br />UN 3291, PG II
<br />Stockton CA 95n,:
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />SERVICE DATE II;U8i06 10:52 of) ^M
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />_
<br />SHIPPING UUCUMEN I t: MDFR00t
<br />UN 3291, PG II
<br />A5111A1fll MFIJ; CAL WASTE 6.2, :11;7NI ;.; .,
<br />I'
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />uF
<br />TOTAL VOLUME COLLECTED: 23 6 CU r1
<br />UN 3291, PG II
<br />19,9
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />�; o e �: _ i;t • _- . -?
<br />Z
<br />UN 3291, PG II
<br />T814 44 Gal Tub(Bio), ) 3 ',
<br />UJ
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />_
<br />1101A014 161,1 uuAOul' 1014 4l0WO TB 14
<br />UN 3291, PG II
<br />OOAOOIN TBA
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />:u F
<br />!are that tb . i '.....;, .:f tl ,
<br />UN 3291, PG II
<br />,,e fully and dralel.
<br />:u F
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />cby
<br />lassified. par' 1
<br />UN 3291, PG II
<br />Iacardetl I r in all
<br />per condi: ,,,1
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOY)
<br />I
<br />nal i„i ! � . •;ni.irnta � ,' ; .
<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 governm tal regpiptie
<br />Printed/Typed Name' Signature
<br />4. TRANSPORTER 1 AQDRESS
<br />r
<br />a
<br />CL z
<br />TRANSPORTED CERTIFICATIO . Receipt of medical waste as descdbect64e:
<br />�,i',' �`/°'rt x
<br />'r Signature*
<br />Print/Type Name
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
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<br />F
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described ab
<br />Z
<br />Print/Type Name Signature
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<br />8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
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<br />t aw
<br />au
<br />Zwi
<br />
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