|
010190 Stericyclie
<br />ILAK nrnr - amtst
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-234-0051
<br />Mw
<br />w � W
<br />�2i UjJ
<br />W
<br />g
<br />z w i
<br />Q~
<br />Z
<br />F —
<br />1. Generator's Name, Address and Tel one Number
<br />7. DISCREPANCY INDICATION
<br />I` SERVICE RECEIPT
<br />�1
<br />❑ SA. Designated Facility:
<br />j
<br />❑ 8D. Alternate Facility 8E. Alternate Facility:
<br />J
<br />U H
<br />Autoclavable Treatment
<br />Autoclavable Treatment Autoclavable Treatment
<br />ACCOUNT
<br />Stericycle, Inc.
<br />p
<br />CUSTOMER OMER STOCKTON MEDICAL PLAZA
<br />LL 5 3
<br />2775 E. 26th Street
<br />1345 Doolittle Drive, Suite C 4135 W. Swift Avenue
<br />SERVICE DATE: 12127106 10:19:00 AM
<br />m
<br />E
<br />Vernon, CA 90023
<br />,.
<br />DRIVER ID: BS1
<br />Z j.!
<br />Lu
<br />(323) 362-3000
<br />(510) 562-1781 (559) 275-0994
<br />SHIPPING DOCUMENT II: NUFRO04L I D---------------
<br />—
<br />MWTF Permit # P-115
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />TOTAL CONTAINERS COLLECTED. 3
<br />j
<br />MWTS Permit # TS/0ST-25
<br />TOTAL VOLUME COLLECTED, 17 7 CU Fl
<br />q &
<br />W o
<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 />2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE
<br />-- - --
<br />wastes in accordance with the requirement outlined in that authorization.
<br />�m
<br />REGULATED MEDICAL WASTE, nos 6.2,
<br />I 0OA0030 TB14 ODA003N TB14 0OA003M T514
<br />UN 3291, PG II : f ?'.;:
<br />i
<br />Date
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2
<br />F
<br />VOL
<br />UN 3291, PG III
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,E "'
<br />SUMMARY(By ContType) QTY CF
<br />Cu
<br />®
<br />UN 3291, PG II 7,` °
<br />v
<br />3 17.7
<br />Cu
<br />QREGULATED
<br />MEDICAL WASTE, n.o.s., 6.2; - -.:.
<br />I TB14 44 Gal Tub(Bio),
<br />—
<br />x
<br />UN 3291, PG II
<br />Cu
<br />W
<br />Z
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />DELIVERY DOCUMENT POFRO04LID
<br />—
<br />W
<br />UN 3291, PG II
<br />_
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />TOTAL DELIVERED ITEMS: 3
<br />UN 3291, PG 11
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />ITEM QTY
<br />UN 3291, PG 11
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,TB14
<br />44 Gal Tub(Bio), C 3
<br />UN 3291, PG II
<br />Cu
<br />Cu
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®TAC..
<br />Cu
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in proffer condition for transport according to applicable international and national governmental regulations."
<br />Printed/Typed Name Signature
<br />Date
<br />-
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone #: c_
<br />LU
<br />}v Cr
<br />Applicable Permit Numbers:
<br />O.:�
<br />`w
<br />p� Q
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />~
<br />zg i
<br />n
<br />Z
<br />g%
<br />_
<br />e
<br />Print/Type Name 4 - Signature i
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />N W
<br />w~Qm
<br />Applicable Permit Numbers:
<br />a 53LuJ
<br />W
<br />O
<br />Zw=
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described
<br />above.
<br />Print/Type Name Signature
<br />Date
<br />Mw
<br />w � W
<br />�2i UjJ
<br />W
<br />g
<br />z w i
<br />Q~
<br />Z
<br />F —
<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 />❑ SA. Designated Facility:
<br />8B. AlternateFacility:0'8C, Alternate Facility:
<br />❑ 8D. Alternate Facility 8E. Alternate Facility:
<br />J
<br />U H
<br />Autoclavable Treatment
<br />Autoclavable Treatment Autoclavable Treatment
<br />Incineration Treatment
<br />Stericycle, Inc.
<br />Stericycle, Inc. Stericycle, Inc.
<br />Stericycle, Inc.
<br />LL 5 3
<br />2775 E. 26th Street
<br />1345 Doolittle Drive, Suite C 4135 W. Swift Avenue
<br />90 North 1100 West
<br />m
<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 j.!
<br />Lu
<br />(323) 362-3000
<br />(510) 562-1781 (559) 275-0994
<br />Class V Incineration
<br />m
<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 />MWTS Permit # TS/0ST-25
<br />Treatment by incineration
<br />q &
<br />W o
<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 />Xa
<br />received the above indicated
<br />wastes in accordance with the requirement outlined in that authorization.
<br />�m
<br />Print/Type Name
<br />Signature
<br />Date
<br />
|