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<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-234-0051
<br />lift SERVICE RECEIPT
<br />1 ACCOUNT #: 6070300-001
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<br />1CUSTOMER NAME Stockton Medical Plaza
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<br />SERVICE DATE 01 103107 11:15: oo AM
<br />DRIVER 10: BSI
<br />SHIPPING DOCUMENT a MDF ROu4MGE
<br />TOTAL CONTAINERS COLLECTED: 2
<br />TOTAL VOLUME COLLECTED: 11.8 CU FI
<br />OOA0031 T814 OCA003H T814
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<br />2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, .;
<br />GENERATOR'S REGISTRATION #
<br />VOL
<br />SUMMARy(By ContType) QTY CF
<br />T814 44 Gal Tub(Bio), 2 11.8
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<br />TOTAL DELIVERED ITEMS: 2
<br />ITEM QT4
<br />TB14 44 Gal Tub(Bio), C 2
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />TOTALS 10
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />Date
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />VOL
<br />SUMMARy(By ContType) QTY CF
<br />T814 44 Gal Tub(Bio), 2 11.8
<br />UEL I VERY DOCUMENT III: POFRO04MGE
<br />TOTAL DELIVERED ITEMS: 2
<br />ITEM QT4
<br />TB14 44 Gal Tub(Bio), C 2
<br />LEAVE AT GENERATOR ii2!31d,
<br />7. DISCREPANCY INDICATION
<br />TOTALS 10
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
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<br />are in all respects in proper condition for transport according to applicable international and national ggvernmental regulations."
<br />Stericycle, Inc.
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<br />2775 E. 26th Street
<br />Printed/Typed Name Signature
<br />Date
<br />vVernon,
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<br />Phone #: f 7_ `�� 7 7'7
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<br />Applicable Permit Numbers:
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<br />MWTF Permit # TS -31 MWTS/OST Permit # TS/OST-22
<br />Permit #91-02
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<br />TRANSPORTER, CERTIFICATION: Receipt of'medical waste as descrbed.. above )
<br />MWTS Permit # TS/OST-25
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<br />Print/Type Name *' Signature
<br />Date
<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 />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
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<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Date
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
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<br />Date
<br />LEAVE AT GENERATOR ii2!31d,
<br />7. DISCREPANCY INDICATION
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<br />❑ 8A. DesignatedFacility:El
<br />8B. Alternate Facility: EPC. Alternate Facility:
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<br />Stericycle, Inc.
<br />Stericycle, Inc. Stericycle, Inc.
<br />Stericycle, Inc.
<br />LL 0 3
<br />2775 E. 26th Street
<br />1345 Doolittle Drive, Suite C 4135 W. Swift Avenue
<br />90 North 1100 West
<br />North Salt Lake, UT 84054
<br />vVernon,
<br />CA 90023
<br />San Leandro, CA 94577 Fresno, CA 93722
<br />(801) 936-1555
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<br />(323) 362-3000
<br />(510) 562-1781 (559) 275-0994
<br />Class V Incineration
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<br />MWTF Permit # P-115
<br />MWTF Permit # TS -31 MWTS/OST Permit # TS/OST-22
<br />Permit #91-02
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<br />MWTS Permit # P-6
<br />MWTS Permit # TS/OST-25
<br />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
<br />Signature
<br />Date
<br />LEAVE AT GENERATOR ii2!31d,
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