|
I
<br />a 0 0 mmu
<br />as sterkyCle, IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-234-0051
<br />1. Generator's Name, Address and Telem9ne Number
<br />6
<br />CUSTOMER NUMBER
<br />2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE
<br />REGULATED MEDICAL WASTE, ri.os.,6.2,
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />T
<br />UN 3291 PG 11
<br />GENERATOR'S REGISTRATION #
<br />REGULATED MEDICAL WASTE, n.o,s., 6.2,
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, mo.s.,6.2,
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, ri.O.S.,6.2,
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, ri.o.s., 6.2,
<br />UN 3291, PG 11
<br />SERVICE RECEIPT
<br />ACCOUNT 11: 6070300-001
<br />C1 jSTIiM[R N.,'jMF Sutter Gou I d /S tu,', I. li, Mr
<br />SERVICE DATE 02/14/07 09:30:00 AM
<br />DRIVER 10: EIS1
<br />SHIPPING DOCUMENT 0: MOFR004SE3
<br />--------------
<br />TOIAL CONTAINERS COLLECTED: 6
<br />TOTAL VOLUME COLLECTED: 35.4 CU F]
<br />----------------
<br />wAu(19P I a ! 4 0OA009S T914 1.4.4.4v40 TbN
<br />ulAt)WN TB 14 0OA004M T814 a0A0,041- TB 14
<br />---------------
<br />VOL
<br />SUMMARY(By ContType) QTY CF
<br />TBA 44 Gal Tub(Bio), 6 35.4
<br />---- ------ ---
<br />DELIVERY DOCUMENT III: PDFRO04S1:3
<br />------------ ---
<br />TOTAL DELIVERED ITEMS: 6
<br />I TEM QTY
<br />T914 44 Gal Tub(Bio), C 6
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in proper cQpdition for transport according to applicable international and natipnal,governmental regulations."
<br />XPrinted/Typed Name Signature Date
<br />IX 4. TRANSPORTER 1ADDRESS: Phone #:
<br />UJI
<br />Applicable Permit Numbers:
<br />0
<br />CL Z TRANSPORTER..CF.
<br />-PITIFICATIOW Receipt of medical waste as described above
<br />Print/Type Name -Signature Date
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone #:
<br />L05 !R a: Applicable Permit Numbers:
<br />a 3 L
<br />0 U3
<br />2 *
<br />Z
<br />,W
<br />Z UJ< INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />P=
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 TRANSPORTER 3 ADDRESS: Phone #:
<br />Lu
<br />UWJ Applicable Permit Numbers:
<br />U.1
<br />020
<br />zItZ INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />UJI
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facility:
<br />8B. Alternate Facility: fa!IiC. Alternate Facility: 0 8D. Alternate Facility: El 8E. Alternate Facility:
<br />M
<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />LL3 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(801) 936-1555
<br />Z (323) 362-3000 (510) 562-1781 (559) 275-0994
<br />LLJ Class V Incineration
<br />MWTF Permit # P-115 MWTF Permit # TS -31 MWTS/OST Permit # TS/OST-22 Permit #91-02
<br />MVVTS Permit # P-6 MWTS Permit # TS/OST-25 Treatment by incineration
<br />Uj 0 TREATMENT MEN r FACILITY, I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />t received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />LEAVE AT GENERATOR
<br />
|