|
000 Stericycle,
<br />0.0
<br />A&
<br />wor_v@%,^L vvmo i = I r%A�,mim%2 rwrmyv munnocrt
<br />1. Generator's Name, Address and Tel one Number
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. 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, ri.o.s.,6.2,
<br />7
<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 />�4_
<br />Cu F
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />Cu F
<br />III
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />Z
<br />UN 3291, PG 11
<br />Cu F
<br />LU
<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.as.,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
<br />Cu F
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/plapAded, and
<br />are in all respects in propeF condition for transport according to applicable international and natianal'66v6rnmental regulations."
<br />X Printed/Typed Name ------- L_m� A i Signature
<br />Date
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone #:
<br />U.1
<br />Applicable Permit Numbers:
<br />Ix
<br />0
<br />(L Z
<br />TRANSPORTER-CERTIf ICATION: Receipt of medical waste as describedb"
<br />ja ove,
<br />%
<br />Print/Type Name Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />"u,
<br />L'u W
<br />Applicable Permit Numbers:
<br />LU _j
<br />020
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />99
<br />Print/Type Name Signature
<br />Date
<br />Uj
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Qui ¢ W
<br />Applicable Permit Numbers:
<br />F- W
<br />02
<br />zZ
<br />W <
<br />W
<br />INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />P =
<br />Z
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facility: 8B. Alternate Facility: 0,8G,Aiternate Facility: El 8D. Alternate Facility:
<br />0 8E. Alternate Facility:
<br />-T
<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />.
<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />U. 0
<br />2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />ii.—
<br />North Salt Lake, LIT
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722
<br />84054
<br />Z 3 E
<br />(801) 936-1555
<br />(323) 362-3000 (510) 562-1781 (559) 275-0994 Class V Incineration
<br />Ll,!
<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/OST-25 Treatment by incineration
<br />LU
<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 />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />PrintlType Name —Signature
<br />Date
<br />
|