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Sao Stericyclee
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<br />IN CASE OF EMERGENCY CONTACT TEAR CHEMTREC 1-800-234-0051 HERE
<br />1. Generator's Name, Address and TeleWne Number
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />P
<br />7. DISCREPANCY INDICATION
<br />Y;ain, �Wi�4j J=Qjg! 7 -%*4 Vin-
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<br />8A. Designated Facility:
<br />F 8B. Alternate Facility: 8C. Alternate Facility:
<br />El 8D. Alternate Facility: El 8E. Alternate Facility;
<br />❑
<br />SERVICE RECEIPT
<br />31
<br />Incineration Treatment
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<br />Stericycle, Inc.
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<br />Stericycle, Inc.
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<br />1345 Doolittle Drive, Suite C 4135 K Swift Avenue
<br />90 North 1100 West
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<br />DAME SU [TER GOULD W4
<br />San Leandro, CA 94577 Fresno, CA 93722
<br />North Salt Lake, LIT 84054
<br />(801) 936-1555
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<br />LLJ
<br />OATS: 11/22416 1215:00 PH
<br />f 44 4_5
<br />Class V Incineration
<br />up, I VER 10): BSI
<br />MWTF Permit # TS -31 MWTS/OST Permit# TS/OST-22
<br />Permit #91-02
<br />SfllppjN(j OuC!)RENT It: HDFR004GUY
<br />CUSTOMER NUMBER 1) j
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<br />GENERATOR'S REGISTRATION #
<br />TOTAL CONTAINERS COLLFUELI: 6
<br />2A. DESCRIPTION OF WASTE 2B.
<br />CONTAINER TYPE
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<br />IOIAL vuLumE (XILECTED. 35 4 LU 1
<br />REGULATED MEDICAL WASTE, ri.o.s.,6.2, "...
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<br />Print/Type Name
<br />OOAOOIIN T814
<br />UN 3291, PG 11
<br />oJ,',.0uN 7814
<br />013A001Z T014 ui,I10,ilf Tl);4
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,-
<br />UN 3291 PG 11
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<br />Uµ1;020 T9414
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2, f" T: D> 1 .3 4 -1 c., TL
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, ri.o.s.,6.2, 1: 7"' 7777 '7 77 7
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, ri.o.s.,6.2, 7,R15 � rn z 2.a f -,7,
<br />I UN 3291, PG 11 1
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, fit 1 b i h t-_ir;) �tl Et
<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 I TOTALS 0
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in V,9per condition for transport according to applicable international and national govemmental regulations."
<br />Printed/Typed Name L Signature
<br />4. TRANSPORTER ISAF
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<br />ffR
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<br />_0
<br />Z TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. dX,
<br />Print/Type Name Signature
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
<br />LU
<br />pjo: Z
<br />z INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />VOL
<br />SUMMARY(By CwtType) QTY IF
<br />T1314 44 Gal TWBio), 6 35 4
<br />Lp i , uj Ir NT 0: POFRO04titly
<br />ITEMS: 6
<br />lTEH QTY
<br />?1314 44 Gal fub(biu), I
<br />enone #: �, _� L, :�� ;] w V ., -k
<br />Applicable Permit Numbers:
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
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<br />it I'_
<br />Ui 4 Ix
<br />020
<br />zw < Z
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<br />93
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />Y;ain, �Wi�4j J=Qjg! 7 -%*4 Vin-
<br />8A. Designated Facility:
<br />F 8B. Alternate Facility: 8C. Alternate Facility:
<br />El 8D. Alternate Facility: El 8E. Alternate Facility;
<br />❑
<br />Autoclavable Treatment
<br />Autoclavable Treatment Autoclavable Treatment
<br />Incineration Treatment
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<br />Stericycle, Inc.
<br />Stericycle, Inc. Stericycle, Inc.
<br />Stericycle, Inc.
<br />L.2
<br />3
<br />2775 E. 26th Street
<br />1345 Doolittle Drive, Suite C 4135 K Swift Avenue
<br />90 North 1100 West
<br />E
<br />Vernon, CA 90023
<br />San Leandro, CA 94577 Fresno, CA 93722
<br />North Salt Lake, LIT 84054
<br />(801) 936-1555
<br />Z 1!
<br />LLJ
<br />(323) 362-3000
<br />(510) 562-1781 (559) 275-0994
<br />Class V Incineration
<br />MWTF Permit # P-115
<br />MWTF Permit # TS -31 MWTS/OST Permit# TS/OST-22
<br />Permit #91-02
<br />MWTS Permit# P-6
<br />MVVTS Permit# TS/OST-25
<br />Treatment by incineration
<br />UJI
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency
<br />to accept untreated medical wastes and that I have
<br />W t
<br />received the above indicated
<br />wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name
<br />Signature
<br />Date
<br />LEAVE AT GENERATOR
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<br />
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