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MEDICP
<br />Stericycle ® IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-234.0051
<br />1. Generator's Name, Address and Tele one Number
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<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 colRdition for transport according to applicable international and national governmental regulations.".
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<br />Printed/Typed Name a r_""' ' @ G�5 Signature
<br />SERVICE RECEIPT
<br />ACCOUNT ll. 607030 W
<br />CUSTOMER NAME:SUTTER GOULD NORTH CALIF
<br />SERVICE UATE 12/20/06 01:40:00 PM
<br />DRIVER ID: BSI
<br />--------------
<br />SHIPPING DOCUMENT MDFRO04KOP
<br />TOTAL CONTAINERS COLLECTED: 6
<br />TOTAL VOLUME COLLECTED 35.4 CU FT
<br />0OA002R 1814 004002Q T014 0OA002P T814
<br />0OAO03C T814 0OA0038 TBA 00AU03A T814
<br />--------------
<br />VOL
<br />SUMMARY(By ContType) QTY CF
<br />TB14 44 Gal Tub(8io), 6 35.4
<br />DELIVERY DOCUMENT #, PDFR004K0P
<br />------------
<br />TOTAL DELIVERED ITEMS: 6
<br />ITEM QTY
<br />T814 44 Gal Tub(Bio), C 6
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<br />Date
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<br />CUSTOMER NUMBER
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<br />Phone #:
<br />GENERATOR'S REGISTRATION #
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<br />2A. DESCRIPTION OF WASTE
<br />2B.
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<br />CONTAINER TYPE
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />TRANSPORTER CERTIFICATION: l eceipt ofedicaI waste as ieseobed�bove.
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<br />UN 3291, PG II
<br />Print/Type Name Signature—'.0,'y'
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,P.1
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<br />UN 3291, PG II
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<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 colRdition for transport according to applicable international and national governmental regulations.".
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<br />Printed/Typed Name a r_""' ' @ G�5 Signature
<br />SERVICE RECEIPT
<br />ACCOUNT ll. 607030 W
<br />CUSTOMER NAME:SUTTER GOULD NORTH CALIF
<br />SERVICE UATE 12/20/06 01:40:00 PM
<br />DRIVER ID: BSI
<br />--------------
<br />SHIPPING DOCUMENT MDFRO04KOP
<br />TOTAL CONTAINERS COLLECTED: 6
<br />TOTAL VOLUME COLLECTED 35.4 CU FT
<br />0OA002R 1814 004002Q T014 0OA002P T814
<br />0OAO03C T814 0OA0038 TBA 00AU03A T814
<br />--------------
<br />VOL
<br />SUMMARY(By ContType) QTY CF
<br />TB14 44 Gal Tub(8io), 6 35.4
<br />DELIVERY DOCUMENT #, PDFR004K0P
<br />------------
<br />TOTAL DELIVERED ITEMS: 6
<br />ITEM QTY
<br />T814 44 Gal Tub(Bio), C 6
<br />s J
<br />Date
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<br />TRANSPORTER 1 ADDRESS
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<br />Phone #:
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<br />Applicable Permit Numbers:
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<br />TRANSPORTER CERTIFICATION: l eceipt ofedicaI waste as ieseobed�bove.
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<br />Print/Type Name Signature—'.0,'y'
<br />Date
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
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<br />0: Applicable Permit Numbers:
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<br />i INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />°- Print/Type Name Signature Date
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<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />W _q M Applicable Permit Numbers:
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<br />W = INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />F — Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION',+
<br />Era ❑ 8A. Designated Facility: ® 8B. Alternate Facility: aaG Alternate Facility: 8D. Alternate Facility: 8E. Alternate Facility:
<br />E6 15
<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />3 Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />LL a 3 2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />iH 9 L2 Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 North Salt Lake, UT 84054
<br />Z °E Cl936-1555
<br />LLI (323) 362-3000 (510) 562-1781 (559) 275-0994 ass V Incineration
<br />MWTF Permit # P-115 MWTF Permit # TS -31 MWTS/OST Permit # TS/OST-22
<br />Permit #91-02
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<br />MWTS Permit # P-6 MWTS Permit # TS/OST-25 Treatment by incineration
<br />L o 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 g received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />LEAVE TGENERATOR �qt4;,,
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