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<br />IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-234-0051
<br />Generator's Name, Address and Tele one Number aINJ s'),
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<br />SERVICE RECEIPT
<br />ACCOUNT 11760�70300- I
<br />i'USIUMILN NAME SUTTER GOULOISTULKIUN HE
<br />SERVICE DATE: 02121107 09:34:00 AM
<br />DRIVER ID: BSI
<br />---- ----- -----
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<br />TOTAL CONTAINERS COLLECTED: 4
<br />TOTAL VOLUME COLLECTED: 23.6 CU F]
<br />GuAutj50 TiEli4 ooAO04X TB14 T814
<br />CUSTOMER NUMBER -i-� -7 f3 1) GENERATOR'S REGISTRATION #
<br />0OA004V T814
<br />2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE
<br />.... .........
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, A
<br />VOL
<br />UN 3291, PG 11
<br />SUMMARY(By ContType) OTY CF
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, 4
<br />UN 3291, PG 11
<br />TELA 44 Gal Tub(Elio), 4 23.6
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, V 44 Z Q;
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<br />UN 3291, PG 11 =--------
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, 1% 7
<br />011.1 VERY DOCUMENT 4: PDFR00416T
<br />UN 3291, PG 11
<br />---------------
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, a-! $P-at�"
<br />TOTAL DELIVERED ITEMS: 4
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<br />LIN 3291, PG 11
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,2,) G a 1. Tub �Chfnne�0 `-2,7 cam,.;tl:)
<br />ITEM QTY
<br />UN 3291, PG 11
<br />TB14 44 Gal Tub(Bio), C 4
<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 />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS
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<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 />'Name
<br />Printed/Typed Signature
<br />Date Z
<br />4. TRANSPORTER DDRESS:
<br />Phone #:
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<br />Applicable Permit Numbers:
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<br />TRANSPORTER', CERTIFICATION: Receipt of medical waste as d above. f
<br />Print/Type Name Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
<br />Phone #:
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<br />05 ti
<br />Applicable Permit Numbers:
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<br />Z
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<br />INTERMEDIATE HANDLER If TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
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<br />6. INTERMEDIATE HANDLER 3 TRANSPORTER 3 ADDRESS:
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION T� ran % f44-8 ctnt a �Aeya-,
<br />❑ 8A. Designated Facility:8B. Alternate Facility:..BC. Alternate Facility: 8D. Alternate Facility:
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<br />El 8E. Alternate Facility:
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<br />Autoclavable Treatment Autoclavable Treatment ;Autoclavable Treatment Incineration Treatment
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<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
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<br />20North
<br />2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
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<br />Salt Lake, LIT
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722
<br />(801) 936-1555
<br />84054
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<br />(323) 362-3000 (510) 562-1781 (559) 275-0994 Class V Incineration
<br />MWTF Permit # P-115 MWTF Permit # TS -31 MWTS/OST Permit # TS/OST-22 Permit #91-02
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<br />MWTS Permit # P-6 MWTS Permit # TS/OST-25 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 Signature
<br />Date
<br />
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