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<br />00 stericycie IN CASE OF EMERGENCY CONTACT: CHENITREC 1-800-234-0031
<br />LEAVE AT GENERATOR
<br />-------------
<br />1. Generator's Name, Address and Tel'Wo-ne Number --
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<br />7 " -,,tLt I P f
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<br />ACCOUNT # 6070300-001
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<br />11"TONIFFt NAME.:SUTI`ER GOULD NORTH
<br />CALIF
<br />pliESERVICE DATE 12/13/06 09:52:00 Am ll".1 A111171-',
<br />DRIVER ID: Eisi
<br />`2
<br />SHIPPING DOCUMENT ,2 - 2,-, ENT It: MOFRO04JU2
<br />TOTAL CONTAINERS COLLECTED: 5
<br />e1 TOTAL VOLUME COLLECTED: 29.5 EU FT
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION # - --- -------
<br />2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 0(,AO02J TB14 0OA002G T814 WA002H TB14
<br />0OA0021 T814
<br />0GA002F T814
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2, 9 o a 2
<br />UN 3291, PG 11
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<br />REGULATED MEDICAL WASTE, n.o.s.,6.2, Z, T
<br />VOL
<br />LIN 3291, PG 11 SUMMARY(By ContType) QTY CF
<br />U F
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2, r '2
<br />0
<br />UN 3291, PG It TBA 44 Gal Tub(Bio), 5 29.5
<br />77 �7
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<br />7 7� 7 7
<br />REGULATED MEDICAL WASTE, ri.o.s.,6.2, T
<br />LIN 3291, PG 11 ---------------
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, TB5 21"', G, a3. .T 1..2.E P a rJ) DELIVERY DOCUMENT 0: POFR004JU2
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<br />UN 3291, PG It
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<br />REGULATED MEDICAL WASTE, n.o.s.,6.2, TY1 5, ;fit,{ (Gal T WZ ,C I-, wn, 0.i %2 - C11 TOTAL DELIVERED ITEMS: 5 f t'�
<br />LIN 3291, PG 11
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<br />REGULATED MEDICAL WASTE, ri.o.s.,6.2, ITEM QTY
<br />UN 3291, PG 11
<br />T814 44 Gal Tub(Bio), C
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<br />REGULATED MEDICAL WASTE, n.o.s_6.2, 5
<br />UN 3291, PG 11
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TO
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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 respects in proper condition for transport according to applicable international and nationakgovernmental regula
<br />Printed/Typed NameSignature Date
<br />4. TRANSPORTER 1,ADDRFSS:,,,. Phone #: 7
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<br />Applicable Permit Numbers:
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<br />41-3,5 11`5qe,.z0-1 S'*.-ifAvE�..
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<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as describebov
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<br />— —Date
<br />Print/Type Name Signature
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone #:
<br />gW
<br />Applicable Permit Numbers:
<br />LU
<br />0
<br />ED
<br />0
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />93
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone
<br />Ix < �_
<br />Weg
<br />Applicable Permit Numbers:
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<br />LU
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<br />INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />X—
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION Twn�,?aed ft to
<br />5
<br />F-1 8A. Designated Facility: ❑0 8B. Alternate Facility: C. Alternate Facility: 8D. Alternate Facility: El 8E. Alternate Facility:
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<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
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<br />Stericycle, Inc. Stericycle, Inc. " Stericycle, Inc. Stericycle, Inc.
<br />U. 13
<br />2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />North Salt Lake, LIT 84054
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<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 (801) 936-1555
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<br />(323) 362-3000 (510) 562-1781 (559) 275-0994 Class V Incineration
<br />Permit # TS/OST-22
<br />MWTF Permit # P-115 MWTF Permit # TS -31 MWTS/OST 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
<br />IX
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />PrintlType Name Signature Date
<br />LEAVE AT GENERATOR
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