|
re hilt ItiAn n 11
<br />5tericfcle ® IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-234-0051
<br />'I. Generator's Name, Address and Tele ne Number
<br />p NOW
<br />y I +ii
<br />' ?.g.I 4
<br />GENERATOR'S REGISTRATION #
<br />CONTAINER TYPE
<br />Y�
<br />a _ 'i x ga3.= T" ,
<br />'�. "..., .. .y,� !fir ;i �'.+e; :"."✓w �.�.,j
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I 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 condition for transport according to applicable international and natlonal,governmental regulations."
<br />Printed/Typed Name - Signature
<br />IX 4. TRANSPORTER 1 ADDRESS:
<br />LLJ
<br />a.
<br />Q TRANSPORTER CERTIFICATION' 'Receipt of medical waste as described above
<br />C t S a 4 ?t
<br />Print/Type Name Signature 4'',K
<br />---�-----
<br />SERVICE RECEIPT
<br />ACCOUNT 4: 6070300-001
<br />CUSTOMER NAME Sutter Gould/Sto 4 tun Me
<br />SERVICE DATE: 01124107 10:59A0 AM
<br />DRIVER ID: BS1 --------------
<br />SHIPPING
<br />SHIPPING DOCUMENT 4_ MOFRO04PC2
<br />TOTAL CONTAINERS COLLECTED: 6
<br />TOTAL VOLUME COLLECTED: 35.4 CU Ff
<br />----------
<br />()A0050 T814 0OA005L T814 n0A005K TB14
<br />00A005! T814 OCA0054 T814 OCAOl15M T814
<br />VOL
<br />SUMMARY(By Contiype) QTY CF
<br />T814 44 Gal Tub(8i0)1 6 35.4
<br />---------------
<br />DELIVERY
<br />ELIVERY DOCUMENT fl: PDFR004PC2
<br />TOTAL DELIVERED ITEMS: 6
<br />QTY
<br />ITEM
<br />T814 44 Gal Tub(810), C 6
<br />vale
<br />Phone #:r. <; rs k,1ti.K
<br />Applicable Permit Numbers:
<br />Date
<br />N
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br />LU Applicable Permit Numbers:
<br />t2 0 ww
<br />g
<br />Z w = INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />~ Print/Type Name Signature Date
<br />w
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />w Q Applicable Permit Numbers:
<br />LU
<br />irQJ
<br />W
<br />050
<br />W w a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />'M~
<br />Z
<br />y' Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facility: 8B. Alternate Facility:
<br />8G. Alternate Facility: 8D. Alternate Facility: 08E. Alternate Facility:
<br />❑ s y: ❑ y: a �v ❑ ❑
<br />E Autoclavable Treatment Autoclavable Treatment A clavable Treatment Incineration Treatment
<br />s Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 North Salt Lake, UT 84054
<br />F 323 362-3000 510 562-1781 559 275-0994 (801) V Incineration W � � ( ) � ) ( ) Class V Incineration
<br />MWTF Permit # P-115 MWTF Permit # TS -31 MWTS/OST Permit # TS/OST-22 Permit #91-02
<br />p— A MWTS Permit # P-6 MWTS Permit # TS/OST-25 Treatment by incineration
<br />UJIo , TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />Wa received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />CUSTOMER NUMBER .•;.,,.
<br />2A. DESCRIPTION OF WASTE
<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 />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 />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />Id,l
<br />WUN
<br />3291, PG II
<br />Uj
<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 />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />p NOW
<br />y I +ii
<br />' ?.g.I 4
<br />GENERATOR'S REGISTRATION #
<br />CONTAINER TYPE
<br />Y�
<br />a _ 'i x ga3.= T" ,
<br />'�. "..., .. .y,� !fir ;i �'.+e; :"."✓w �.�.,j
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I 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 condition for transport according to applicable international and natlonal,governmental regulations."
<br />Printed/Typed Name - Signature
<br />IX 4. TRANSPORTER 1 ADDRESS:
<br />LLJ
<br />a.
<br />Q TRANSPORTER CERTIFICATION' 'Receipt of medical waste as described above
<br />C t S a 4 ?t
<br />Print/Type Name Signature 4'',K
<br />---�-----
<br />SERVICE RECEIPT
<br />ACCOUNT 4: 6070300-001
<br />CUSTOMER NAME Sutter Gould/Sto 4 tun Me
<br />SERVICE DATE: 01124107 10:59A0 AM
<br />DRIVER ID: BS1 --------------
<br />SHIPPING
<br />SHIPPING DOCUMENT 4_ MOFRO04PC2
<br />TOTAL CONTAINERS COLLECTED: 6
<br />TOTAL VOLUME COLLECTED: 35.4 CU Ff
<br />----------
<br />()A0050 T814 0OA005L T814 n0A005K TB14
<br />00A005! T814 OCA0054 T814 OCAOl15M T814
<br />VOL
<br />SUMMARY(By Contiype) QTY CF
<br />T814 44 Gal Tub(8i0)1 6 35.4
<br />---------------
<br />DELIVERY
<br />ELIVERY DOCUMENT fl: PDFR004PC2
<br />TOTAL DELIVERED ITEMS: 6
<br />QTY
<br />ITEM
<br />T814 44 Gal Tub(810), C 6
<br />vale
<br />Phone #:r. <; rs k,1ti.K
<br />Applicable Permit Numbers:
<br />Date
<br />N
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br />LU Applicable Permit Numbers:
<br />t2 0 ww
<br />g
<br />Z w = INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />~ Print/Type Name Signature Date
<br />w
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />w Q Applicable Permit Numbers:
<br />LU
<br />irQJ
<br />W
<br />050
<br />W w a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />'M~
<br />Z
<br />y' Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facility: 8B. Alternate Facility:
<br />8G. Alternate Facility: 8D. Alternate Facility: 08E. Alternate Facility:
<br />❑ s y: ❑ y: a �v ❑ ❑
<br />E Autoclavable Treatment Autoclavable Treatment A clavable Treatment Incineration Treatment
<br />s Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 North Salt Lake, UT 84054
<br />F 323 362-3000 510 562-1781 559 275-0994 (801) V Incineration W � � ( ) � ) ( ) Class V Incineration
<br />MWTF Permit # P-115 MWTF Permit # TS -31 MWTS/OST Permit # TS/OST-22 Permit #91-02
<br />p— A MWTS Permit # P-6 MWTS Permit # TS/OST-25 Treatment by incineration
<br />UJIo , TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />Wa received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />
|