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<br />,so Stericycle, IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-234.0051
<br />LEAVE AT GENERATOR
<br />1. Generator's Name, Address and Tele one Number
<br />SERVILE RECEIPT
<br />---------------
<br />ACCOUNT 111: 6070300-001
<br />CliSIUMB NA*SUTTER GOULD/SIUCKIIJN MI
<br />SERVICE DATE! 01/26107 10:41:00 AM
<br />DRIVER 10: EIS1
<br />.2
<br />SHIPPING DOCUMENT It: MDFRBS0126
<br />--------------
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />TOTAL CONTAINERS COLLECTED: 3
<br />fol -AL VOLUME COLLECTED: 17.7 CU F
<br />2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE
<br />-------------
<br />(140(.6P TBA 0OA0050 T814 (PA005p T8141
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />----------------
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,--
<br />VOL
<br />LIN 3291, PG 11
<br />SUMMARY(By ContType) QTY CF
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />0
<br />UN 3291, PG 11
<br />T814 44 Gal Tub(Elia), 3 173
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />---------------
<br />1.11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />DELIVERY oocumENT 1: POFROS0126
<br />Z
<br />UN 3291, PG 11
<br />---- ---------
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />TOTAL DELIVERED ITEMS: 3
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />ITEM QTY
<br />UN 3291, PG 11
<br />TB14 44 Gal Tub(Bio), C 3
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />LIN 3291, PG 11
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately LS 0
<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 national governmental regulations."
<br />Printed/Typed Name Signature
<br />Date
<br />IX
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone
<br />W
<br />1--
<br />Applicable Permit Numbers:
<br />IX
<br />0
<br />IL
<br />M
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<br />I/
<br />TRANSPORTER,,CERTIFICATIONO" Receipt of medical waste as clescribejd above
<br />.#-"/
<br />Print/Type Name —Signature
<br />Date 3
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
<br />Phone
<br />�oui
<br />Applicable Permit Numbers:
<br />-j
<br />wo
<br />[L W -
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />U.1
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Ix �-�
<br />Lu x
<br />Applicable Permit Numbers:
<br />O BLU
<br />LU J
<br />I
<br />02 0
<br />ZZ
<br />-
<br />INTERMEDIATE HANDLER /TRANSPORTER RTER CERTIFICATION: Receipt of medical waste as described above.
<br /><
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />F] 8A. Designated Facility: ❑ 8B. Alternate Facility: �8—C- Alternate Facility: D 8D. Alternate Facility:
<br />8E. Alternate Facility:
<br />:3
<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />LL 'oi32775
<br />E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />E
<br />-f.
<br />North Salt Lake, LIT
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722
<br />(801) 936-1555
<br />84054
<br />Z E
<br />(323) 362-3000 (510) 562-1781 (559) 275-0994 Class V Incineration
<br />9
<br />9
<br />MWTF Permit # P-115 MVVTF 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 />LLI s
<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 />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />Date
<br />LEAVE AT GENERATOR
<br />
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