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<br />Stericycle
<br />IN CASE OF EMERGENCY CONTACT: CHEIVITREC 1-800-234-0051
<br />1. Generator's Name, Address and Tellrhone Number
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<br />CUSTOMER NUMBER
<br />GENERATOR'S REGISTRATION #
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<br />2A. DESCRIPTION OF WASTE
<br />1213
<br />CONTAINER TYPE
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />F1 8B. Alternate Facility: E j r Alternate Facility: _
<br />® 81). Alternate Facility:0 SE. Alternate Facility:
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<br />UN 3291, PG II
<br />Atbtoclavable Treatment
<br />Incineration Treatment
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />UN 3291, PG II
<br />2775 E. 26th Street
<br />1345 Doolittle Drive, Suite C
<br />4135 W. Swift Avenue
<br />90 North 1100 West
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />I— 17
<br />Vernon, CA 90023
<br />San Leandro, CA 94577
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<br />UN 3291, PG II
<br />Z 3 E
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<br />(323) 362-3000
<br />(510) 562 1781
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />(801) 936-1555
<br />Class V Incineration
<br />MWTF Permit # P-115
<br />UN 3291, PG II
<br />MWTS/OST Permit # TS/OST-22
<br />Permit #91-02
<br />I—
<br />a ;TREATMENT
<br />REGULATED MEDICAL WASTE, n,o.s., 6.2,a
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<br />3.
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<br />UN 3291, PG II
<br />FACILITY: I certify
<br />that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />a
<br />,a.
<br />UN 3291, PG II
<br />WASTE, n.o.s., 6.2,I . ? :x'=
<br />REGULATED MEDICAL WASTE, n.o.s.,
<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s.,
<br />UN 3291, PG II
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS'
<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 />Printed/Typed Name `"' Signature >
<br />IY 4. TRANSPORTER 1 ADDRESS
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<br />!Y 4 1 'WF -. a i
<br />a
<br />_�. ,-, �'� $ �1 _sty. �K
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<br />ZTRANSPORTER CERTIFICATION: Receipt of medical waste as described abovei'
<br />Print/Type Name Signature
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
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<br />Ix FW—ceW
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<br />20
<br />Zu a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />I
<br />� Print/T a Name
<br />YP Signature
<br />M w 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Uj :, 0:
<br />IX ® J
<br />W
<br />2
<br />z0: a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />I—
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<br />Print/Type Name Signature
<br />---------------
<br />SERVICE RECEIPT
<br />------------
<br />ACCOUNT 4: 607638
<br />SERVICERDATE: 0410410NAMESUTTE70 OD21T00 ATON M NE
<br />DRIVER 10: BS1
<br />-------------
<br />SHIPPING DOCUMENT 4: MOFR004Z39
<br />TOTAL CONTAINERS COLLECTED: 6
<br />TOTAL VOLUME COLLECTED: 35.4 CU FT
<br />OOAOnOC TB14 00A0009 TB14 00008 TB14
<br />OOA0007 T914 OOAOOOA T814 00A000B TB14
<br />VOL
<br />SUMMARV(By ContType) QTV CF
<br />T814 44 Gal Tub(Bio), 6 35.4
<br />---------------
<br />DELIVERY DOCUMENT t: POFR004Z39
<br />TOTAL DELIVERED ITEMS: 3
<br />ITEM QTY
<br />TB57 90 Gal Tub(Bio)CT 3
<br />Date {
<br />Phone # '.S '
<br />Applicable Permit Numbers:
<br />x
<br />a
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />Phone #: --
<br />Applicable Permit Numbers:
<br />Date
<br />1. UIZ�UKtHANUY INIJIGAI ION
<br />q
<br />8A. Designated Facility:
<br />F1 8B. Alternate Facility: E j r Alternate Facility: _
<br />® 81). Alternate Facility:0 SE. Alternate Facility:
<br />J 5
<br />Autoclavable Treatment
<br />Autoclavable Treatment
<br />Atbtoclavable Treatment
<br />Incineration Treatment
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />LL 5 3
<br />2775 E. 26th Street
<br />1345 Doolittle Drive, Suite C
<br />4135 W. Swift Avenue
<br />90 North 1100 West
<br />I— 17
<br />Vernon, CA 90023
<br />San Leandro, CA 94577
<br />Fresno, CA 93722
<br />North Salt Lake, LIT 84054
<br />Z 3 E
<br />LU ""
<br />(323) 362-3000
<br />(510) 562 1781
<br />(559) 275 0994
<br />(801) 936-1555
<br />Class V Incineration
<br />MWTF Permit # P-115
<br />MWTF Permit # TS -31
<br />MWTS/OST Permit # TS/OST-22
<br />Permit #91-02
<br />I—
<br />a ;TREATMENT
<br />MWTS Permit # P-6
<br />MWTS Permit # TS/OST-25
<br />Treatment by incineration
<br />uj
<br />FACILITY: I certify
<br />that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />a
<br />received the above indicated
<br />wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name
<br />Signature
<br />Date
<br />
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