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60 Stericicle,
<br />IN CASE OF EMERGENCY CONTACT. CHEIVITREC 1-800-234-0051
<br />1. Generator's Name, Address and Tel one Number.
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<br />CUSTOMER NUMBER
<br />2A. DESCRIPTION OF WASTE
<br />72B--
<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, n.o.s., 6.2,
<br />0
<br />LIN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />7
<br />LIN 3291, PG 11
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />LIN 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, n.o.s., 6.2,
<br />UN 3291, PG 11
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<br />3
<br />I i I A 9. 1111 1A I
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS 0
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and L -
<br />are in all respects in proper -condition for transport according to applicable international and national governmental regulations."
<br />XPrinted/Typed Name' Signature
<br />IX 4. TRANSPORTER 1 ADDRESS:
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<br />as 5y TRANSPORTER- CERTIFICATION: Receipt of medical waste as desafl5bd �66'ove.
<br />Print/Type Name Signature Date
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
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<br />ILZU!R X 'Applicable Permit Numbers:
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<br />Z INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 TRANSPORTER 3 ADDRESS: Phone #:
<br />LUIX Applicable Permit Numbers:
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<br />U)W< INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
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<br />F'j 8A. Designated Facility: 8B. Alternate Facility: M,,,'8c. Alternate Facility: ~ D 8D. Alternate Facility: El 8E. Alternate Facility:
<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />LL. 2 2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />s North Salt Lake, LIT 84054
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 (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 />MWTS Permit # P-6 MWTS Permit # TS/CST-25 Treatment by incineration
<br />Ujo TREATMENT FACILITY. I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />Xa received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />2
<br />Print/Type Name Signature Date
<br />SERVICE RECEIPT
<br />ACCOUNT 0: 6070300-001
<br />CUSTOMER NAME Sutter Gould/Stott ton Me
<br />SERVICE DATE: 02128107 12:20:00 PM
<br />DRIVER 10: OS1
<br />SHIPPING DOCUMENT #: MOFRO04UAV
<br />TOTAL CONTAINERS COLLECTED; 6
<br />TOTAL VOLUME COLLECTED: 35A CU FT
<br />----------------
<br />001A060 T814 0OA06L TB14 00M06K T1314
<br />UUAU006J T1314 0OA0006M TBA 00406N TB 14
<br />--------------- I
<br />VOL
<br />SUMMARY(By ContType) QTY CF
<br />TBA 44 Gal Tub(Bio), 6 35.4
<br />-----------
<br />DELIVERY DOCUMENT #: PDFRO04UAV
<br />TOTAL DELIVERED ITEMS: 6
<br />ITEM OTY
<br />TB14 44 Gal Tub(Bia), C 6
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />GENERATOR'S REGISTRATION #
<br />72B--
<br />CONTAINER TYPE
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<br />7
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS 0
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and L -
<br />are in all respects in proper -condition for transport according to applicable international and national governmental regulations."
<br />XPrinted/Typed Name' Signature
<br />IX 4. TRANSPORTER 1 ADDRESS:
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<br />F -
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<br />J-:,� 'a Flh"t-,-,I��,,jh
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<br />as 5y TRANSPORTER- CERTIFICATION: Receipt of medical waste as desafl5bd �66'ove.
<br />Print/Type Name Signature Date
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
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<br />ILZU!R X 'Applicable Permit Numbers:
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<br />Z INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 TRANSPORTER 3 ADDRESS: Phone #:
<br />LUIX Applicable Permit Numbers:
<br />�-25 W j
<br />0: W -j
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<br />ILRZ
<br />U)W< INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />Z3.�� nfwd r, ern,
<br />F'j 8A. Designated Facility: 8B. Alternate Facility: M,,,'8c. Alternate Facility: ~ D 8D. Alternate Facility: El 8E. Alternate Facility:
<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />LL. 2 2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />s North Salt Lake, LIT 84054
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 (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 />MWTS Permit # P-6 MWTS Permit # TS/CST-25 Treatment by incineration
<br />Ujo TREATMENT FACILITY. I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />Xa received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />2
<br />Print/Type Name Signature Date
<br />SERVICE RECEIPT
<br />ACCOUNT 0: 6070300-001
<br />CUSTOMER NAME Sutter Gould/Stott ton Me
<br />SERVICE DATE: 02128107 12:20:00 PM
<br />DRIVER 10: OS1
<br />SHIPPING DOCUMENT #: MOFRO04UAV
<br />TOTAL CONTAINERS COLLECTED; 6
<br />TOTAL VOLUME COLLECTED: 35A CU FT
<br />----------------
<br />001A060 T814 0OA06L TB14 00M06K T1314
<br />UUAU006J T1314 0OA0006M TBA 00406N TB 14
<br />--------------- I
<br />VOL
<br />SUMMARY(By ContType) QTY CF
<br />TBA 44 Gal Tub(Bio), 6 35.4
<br />-----------
<br />DELIVERY DOCUMENT #: PDFRO04UAV
<br />TOTAL DELIVERED ITEMS: 6
<br />ITEM OTY
<br />TB14 44 Gal Tub(Bia), C 6
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />
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