Laserfiche WebLink
a 0 a I <br />00 sterlicycle IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-234-0051 <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTA <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are in all respects,in prflper conditjq�n for transport according to applicable international and national governmental regulations. <br />XPrinted/Typed Name tp Signature <br />Ce 4. TRANSPORTER 1 ADDRESS: Phone #: ( 5 -f-,,- 5: 4-. '7 0 to 4 <br />t ,--e 1: ic-l" 1. e , 1,rc,, Applicable Permit Numbers: <br />4- <br />0 <br />of '212 <br />Ji <br />CL Z TRANSPORTER, CERTIFICATION: Receipt of medical waste as described a'bovdil <br />Print/Type Name Signature Date <br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone #: <br />Ix <br />LU Applicable Permit Numbers: <br />0 U3 <br />0 LU <br />' MZ <br />Z LU= INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone <br />LU <br />UWJ � Applicable Permit Numbers: <br />O auj <br />0 <br />ZWZ <br />Lu < INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />d ❑ 8A. Designated Facility: ❑El 8B. Alternate Facility: D'St. Alternate Facility: 0 8D. Alternate Facility: ❑El 8E. Alternate Facility: <br />gE Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment <br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. <br />2 Z5 90 North 1100 West <br />LL 8 2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue <br />�6 <br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 North Salt Lake, UT 84054 <br />Z (801) 936-1555 <br />UJ (323) 362-3000 (510) 562-1781 (559) 275-0994 Class V Incineration <br />MWTF Permit # P-115 MWTF Permit # TS -31 MWTS/OST Permit # TS/OST-22 Permit #91-02 <br />MWTS Permit # P-6 MWTS Permit # TS/OST-25 Treatment by incineration <br />LL, 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 a received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />Print/Type Name —Signature Date <br />CUSTOMER NUMBER„, <br />VOL <br />GENERATOR'S REGISTRATION # <br />Time; <br />2A. DESCRIPTION OF WASTE <br />2B. <br />Fi <br />CONTAINER TYPE <br />REGULATED MEDICAL WASTE, n.o.s., 6.2, <br />T fY,�, <br />'t <br />11,1� <br />LIN 3291, PG 11 <br />i TLIM <br />o -'L <br />uq <br />T 14 44 Gai b <br />i F1 <br />REGULATED MEDICAL WASTE, n.os., 6.2, <br />LIN 3291, PG 11 <br />REGULATED MEDICAL WASTE, n.o.s., 6.2, <br />0 <br />UN 3291, PG 11 <br />44 <br />REGULATED MEDICAL WASTE, n.o.s., 6.2,T-,�:2 <br />�,j "a.1 <br />T .A"-4 P -L ".A <br />UN 3291, PG 11 <br />III <br />REGULATED MEDICAL WASTE, n.o.s., 6.2, <br />-a <br />2” <br />k <br />i ZI <br />Z <br />UN 3291, PG 11 <br />LU <br />a <br />REGULATED MEDICAL WASTE, n.o.s., 6.2, <br />UN 3291, PG 11 <br />J 3b <br />REGULATED MEDICAL WASTE, n.o.s., 6.2, <br />UN 3291, PG 11 <br />REGULATED MEDICAL WASTE, n.o.s,, 6.2, <br />JUN 3291, PG 11 <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTA <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are in all respects,in prflper conditjq�n for transport according to applicable international and national governmental regulations. <br />XPrinted/Typed Name tp Signature <br />Ce 4. TRANSPORTER 1 ADDRESS: Phone #: ( 5 -f-,,- 5: 4-. '7 0 to 4 <br />t ,--e 1: ic-l" 1. e , 1,rc,, Applicable Permit Numbers: <br />4- <br />0 <br />of '212 <br />Ji <br />CL Z TRANSPORTER, CERTIFICATION: Receipt of medical waste as described a'bovdil <br />Print/Type Name Signature Date <br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone #: <br />Ix <br />LU Applicable Permit Numbers: <br />0 U3 <br />0 LU <br />' MZ <br />Z LU= INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone <br />LU <br />UWJ � Applicable Permit Numbers: <br />O auj <br />0 <br />ZWZ <br />Lu < INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />d ❑ 8A. Designated Facility: ❑El 8B. Alternate Facility: D'St. Alternate Facility: 0 8D. Alternate Facility: ❑El 8E. Alternate Facility: <br />gE Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment <br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. <br />2 Z5 90 North 1100 West <br />LL 8 2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue <br />�6 <br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 North Salt Lake, UT 84054 <br />Z (801) 936-1555 <br />UJ (323) 362-3000 (510) 562-1781 (559) 275-0994 Class V Incineration <br />MWTF Permit # P-115 MWTF Permit # TS -31 MWTS/OST Permit # TS/OST-22 Permit #91-02 <br />MWTS Permit # P-6 MWTS Permit # TS/OST-25 Treatment by incineration <br />LL, 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 a received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />Print/Type Name —Signature Date <br />IF <br />I F1 <br />I F1 <br />Cu F1 <br />Date <br />LEAVE AT GENERATOR sz ",�VW , <br />Al_ _: <br />VOL <br />Time; <br />R <br />Fi <br />F! <br />F! <br />F1 <br />i TLIM <br />uq <br />T 14 44 Gai b <br />i F1 <br />IF <br />I F1 <br />I F1 <br />Cu F1 <br />Date <br />LEAVE AT GENERATOR sz ",�VW , <br />Al_ _: <br />