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<br />1. Generator's Name, Address and TeIeWne Number
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<br />CUSTOMER NUMBER GENERATOR,s REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS IIIJ
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respectsnproper condition for transport according to applicable international and national governmental regulations."
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<br />4. TRANSPORTER 1 ADDRESS: Phone #:
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<br />Applicable Permit Numbers:
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<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
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<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
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<br />INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />7. DISCREPANCY INDICATION
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<br />8B. Alternate Facility: w'$Q'Alternate Facility: El 8E. Alternate Facility:
<br />8A. Designated Facility: F-1 8D. Alternate Facility:
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<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
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<br />2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
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<br />North Salt Lake, UT 84054
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722
<br />(801) 936-1555
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<br />(323) 362-3000 (510) 562-1781 (559) 275-0994 Class V Incineration
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<br />MWTF Permit # P-115 MWTF Permit # TS -31 MWTS/OST Permit # TS/0ST-22 Permit #91-02
<br />MWTS Permit # P-6 MWTS Permit # TS/OST-25 Treatment by incineration
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<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
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