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<br />00 Sterlcycle IN CASE OF EY9ERGENCY. CONTACT: CHEMTREC 1-800-234-0051
<br />1. Generator's Name, Address and TelelWone Number
<br />CUSTOMER NUMBER
<br />SERVICE RECEIPT
<br />AU�.. - -
<br />ACCOUNT 111: 6070300-001
<br />CUSTOMER NAME Sutter Gould/Stocl.Ion Me
<br />SERVICE DATE: 02107107 01:01:00 PM
<br />DRIVER ID: BSI
<br />GENERATOR'S REGISTRATION #
<br />2B CONTAINER TYPE
<br />SHIPPING DOCUMENT #: MDFRO04R7W
<br />----------------
<br />TOTAL CONTAINERS COLLECTED: 6
<br />TOTAL VOLUME COLLECTED: 35.4 CU FT
<br />0A0043 T914 0OA0042 TB14 041 T914
<br />0OA006C T814 0OA0060 T814 i0ou5A T814
<br />--------------
<br />VOL
<br />SUMMARY(By ContType) QTY CF
<br />TB14 44 Gal Tub(Bio), 6 35.4
<br />---------------
<br />DELIVERY DOCUMENT POFRO04R7W
<br />TOTAL DELIVERED ITEMS: 6
<br />ITEM QTY
<br />TB14 44 Gal TUb(BIo), C 6
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS
<br />110
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects ir»,propec condition for transport according to applicable international and national governmental regulations
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<br />Printed/Typed Name t,� Sight� _abate Z,
<br />4. TRANSPORTER 14QQ�iE$3 Phone #:
<br />w � Applicable Permit Numbers:
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<br />2A. DESCRIPTION OF WASTE
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />UN 3291, PG II
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />UN 3291, PG 11
<br />,E,RTIFICATION:
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />Date 2,
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />UN 3291, PG II
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />Applicable Permit Numbers:
<br />UN 3291, PG II
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />20
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />San Leandro, CA 94577 Fresno, CA 93722
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.os., 6.2,
<br />(323) 362-3000
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<br />UN 3291, PG II
<br />SERVICE RECEIPT
<br />AU�.. - -
<br />ACCOUNT 111: 6070300-001
<br />CUSTOMER NAME Sutter Gould/Stocl.Ion Me
<br />SERVICE DATE: 02107107 01:01:00 PM
<br />DRIVER ID: BSI
<br />GENERATOR'S REGISTRATION #
<br />2B CONTAINER TYPE
<br />SHIPPING DOCUMENT #: MDFRO04R7W
<br />----------------
<br />TOTAL CONTAINERS COLLECTED: 6
<br />TOTAL VOLUME COLLECTED: 35.4 CU FT
<br />0A0043 T914 0OA0042 TB14 041 T914
<br />0OA006C T814 0OA0060 T814 i0ou5A T814
<br />--------------
<br />VOL
<br />SUMMARY(By ContType) QTY CF
<br />TB14 44 Gal Tub(Bio), 6 35.4
<br />---------------
<br />DELIVERY DOCUMENT POFRO04R7W
<br />TOTAL DELIVERED ITEMS: 6
<br />ITEM QTY
<br />TB14 44 Gal TUb(BIo), C 6
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS
<br />110
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects ir»,propec condition for transport according to applicable international and national governmental regulations
<br />✓* 4 "
<br />Printed/Typed Name t,� Sight� _abate Z,
<br />4. TRANSPORTER 14QQ�iE$3 Phone #:
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<br />❑ 8A. Designated Facility:
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<br />T NSPORTER receipt of medical waste as descHIS d ab�e J fj
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<br />,E,RTIFICATION:
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<br />Print/Type Name 1 / "" `' Signature �'��
<br />Date 2,
<br />Incineration Treatment
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />Phone #:
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<br />Stericycle, Inc.
<br />Applicable Permit Numbers:
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<br />1345 Doolittle Drive, Suite C 4135 W. Swift Avenue
<br />90 North 1100 West
<br />20
<br />Vernon, CA 90023
<br />San Leandro, CA 94577 Fresno, CA 93722
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<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />(323) 362-3000
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<br />Class V Incineration
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<br />Print/Type Name Signature
<br />Date
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<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #: a,
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<br />Applicable Permit Numbers:
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<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
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<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Signature
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<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION j , a 3 *' nt* toe, i"u I z.;1
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<br />❑ 8A. Designated Facility:
<br />F-1813. Alternate Facility: Q8C. Alternate Facility:
<br />M 8D. Alternate Facility: ❑ 8E. Alternate Facility:
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<br />Autoclavable Treatment
<br />Autoclavable Treatment Autoclavable Treatment
<br />Incineration Treatment
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<br />Stericycle, Inc.
<br />Stericycle, Inc. Stericycle, Inc.
<br />Stericycle, Inc.
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<br />2775 E. 26th Street
<br />1345 Doolittle Drive, Suite C 4135 W. Swift Avenue
<br />90 North 1100 West
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<br />Vernon, CA 90023
<br />San Leandro, CA 94577 Fresno, CA 93722
<br />North Salt Lake, UT 84054
<br />(801) 936-1555
<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/0ST-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
<br />
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