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<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-234-0051
<br />1. Generator's Name, Address and TeMone Number
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<br />GENERATOR'S REGISTRATION #
<br />213. CONTAINER TYPE
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTI
<br />described above by the prWer 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.
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<br />4. TRANSPORTER 1 ADDRESS:
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<br />a. Z TRANSPORTER CERTIFICATION: Receipt of medical waste as described. Bove 8
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<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br />LU 5 Applicable Permit Numbers:
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<br />Zw= INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
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<br />w a IY Applicable Permit Numbers:
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<br />a 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 />❑ 8A. Designated Facility: 88. Alternate Facility: ^ 8C. Alternate Facility: ❑ SD. Alternate Facility: 8E. Alternate Facility:
<br />=d d Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />Stericycle, Inc. Stericycle, Inca Stericycle, Inc. Stericycle, Inc.
<br />3 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
<br />1555
<br />Z " E (323) 362-3000 (510) 562-1781 (559) 275-0994UJ Class V 01) 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/OST-25 Treatment by incineration
<br />Uj 8 TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />1 received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />LEAVE AT GENERATOR
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<br />SERVICE RECEIPT
<br />---------------
<br />ACCOUNT #: 6076382-001
<br />CUSTOMER NAME:SUTTER GOULD/STOCKfON ME
<br />SERVICE DATE: 04/11/07 03:33:00 PM
<br />DRIVER to: BSI
<br />SHIPPING DOCUMENT #; HOFROO502V
<br />---------------
<br />TOTAL CONTAINERS COLLECTED 3
<br />TOTAL VOLUME COLLECTED: 36 CU FT
<br />0140004 T157 OOA0005 TB57 0OA0006 T657
<br />--------------
<br />SUMMARY(By ContType) QTY VOL
<br />CF
<br />TB57 90 Gal Tub(Bio)CT 3 36
<br />---------------
<br />DELIVERY DOCUMENT #, PDFROO502V
<br />TOTAL DELIVERED ITEMS: 6
<br />I TEN QTY
<br />TB14 44 Gal Tub(Bio), C 6
<br />0
<br />Date
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<br />Applicable Permit Numbers:
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<br />CUSTOMER NUMBER ` -
<br />2A. DESCRIPTION OF WASTE
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />3291, PG II
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />61
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<br />GENERATOR'S REGISTRATION #
<br />213. CONTAINER TYPE
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTI
<br />described above by the prWer 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 />�
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<br />Printed/Typed Name i .,'
<br />Signa rue
<br />4. TRANSPORTER 1 ADDRESS:
<br />1 x i !ii s1
<br />a. Z TRANSPORTER CERTIFICATION: Receipt of medical waste as described. Bove 8
<br />Print/Type Name Signature t '
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<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br />LU 5 Applicable Permit Numbers:
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<br />Zw= INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />z Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
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<br />w a IY Applicable Permit Numbers:
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<br />a 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 />❑ 8A. Designated Facility: 88. Alternate Facility: ^ 8C. Alternate Facility: ❑ SD. Alternate Facility: 8E. Alternate Facility:
<br />=d d Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />Stericycle, Inc. Stericycle, Inca Stericycle, Inc. Stericycle, Inc.
<br />3 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
<br />1555
<br />Z " E (323) 362-3000 (510) 562-1781 (559) 275-0994UJ Class V 01) 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/OST-25 Treatment by incineration
<br />Uj 8 TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />1 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 />•)a""<,aas saL.aav: v:"=".'a, :a"._Ssa' 't�a.a
<br />------------
<br />SERVICE RECEIPT
<br />---------------
<br />ACCOUNT #: 6076382-001
<br />CUSTOMER NAME:SUTTER GOULD/STOCKfON ME
<br />SERVICE DATE: 04/11/07 03:33:00 PM
<br />DRIVER to: BSI
<br />SHIPPING DOCUMENT #; HOFROO502V
<br />---------------
<br />TOTAL CONTAINERS COLLECTED 3
<br />TOTAL VOLUME COLLECTED: 36 CU FT
<br />0140004 T157 OOA0005 TB57 0OA0006 T657
<br />--------------
<br />SUMMARY(By ContType) QTY VOL
<br />CF
<br />TB57 90 Gal Tub(Bio)CT 3 36
<br />---------------
<br />DELIVERY DOCUMENT #, PDFROO502V
<br />TOTAL DELIVERED ITEMS: 6
<br />I TEN QTY
<br />TB14 44 Gal Tub(Bio), C 6
<br />0
<br />Date
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<br />Phone #: -2 ", -- 0 9 ra 4
<br />Applicable Permit Numbers:
<br />Date) 1 �� /
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