|
0 a 0 MrIL)QUAL VVAZ I r- 1 KAtoKIrftl rUMPA NUMOr-11%
<br />0 a 0 Stericycle IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-234-0051
<br />A1111111111k Aft
<br />1. Generator's Name, Address and Telepwrie Number
<br />77 -
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />!C: NO. OF
<br />2D. VOLUME
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />CONTAINERS
<br />UN 3291, PG 11
<br />Cu F
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />Cu F
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />0
<br />UN 3291, PG 11
<br />Cu F
<br />REGULATED MEDICAL WASTE, ri.os.,6.2,
<br />UN 3291, PG 11
<br />"A,
<br />Cu F
<br />UJ
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />Z
<br />UN 3291, PG 11
<br />Cu F
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />Cu F
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />Cu F
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />Cu F
<br />Cu F
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 110-
<br />Cu F
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in properconditionfor transport according to applicable international and national. governmental regulations
<br />Ij
<br />x 2
<br />Printed/Typed Name Signature� Date
<br />IX
<br />4. TRANSPORTER 1 ADDRESS: Phone #:
<br />Lu
<br />Applicable Permit Numbers:
<br />"I
<br />0
<br />Z
<br />V
<br />TRANSPORTER CERTIFICATION,` Receipt of medical waste as described ap ovei
<br />TI
<br />0:
<br />F
<br />Print/Type Nam Signature Date
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone #:
<br />UMJ!R Ix
<br />Applicable Permit Numbers:
<br />t2 F3 Lu
<br />Lu _j
<br />0
<br />Q.Za
<br />,WZ
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Zw<
<br />g 9
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />W F--
<br />Applicable Permit Numbers:
<br />IoWIx
<br />i,-
<br />XW-j
<br />020
<br />aINTERMEDIATE
<br />HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />9 Z
<br />F-
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />2 u
<br />1
<br />F-1 8A. Designated Facility: M 8B. Alternate Facility: 8d. Alternate Facility: 8D. Alternate Facility: 0 BE. Alternate Facility:
<br />E]
<br />g'
<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />2�
<br />-� ti
<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />LL 0 3
<br />2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />North Salt Lake, UT 84054
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 (801) 936-1555
<br />Z 3(323)
<br />LLJ A'
<br />362-3000 (510) 562-1781 (559) 275-0994 Class V Incineration
<br />g
<br />MWTIF 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 />Uj
<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 />IX t
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />
|