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IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-234-0051
<br />1. Generator's Name, Address and Te one Number
<br />SERVICE HtLtIVI -
<br />ACCOUNT 6076382-001
<br />Sutter Gould/Stockton Me
<br />CUSTOMER NAME.Sutter
<br />SERVICE DATE: 05111107 09:48:00 AN
<br />DRIVER 10i BS1
<br />---------------
<br />HIppIMG DOCUMENT III MOFRBS0511
<br />----------------
<br />TOTAL CONTAINERS COLLECTED: 2
<br />TOTAL VOLUME COLLECTED: 11.8 CU FT
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />OOA0o0Q T814 0000 TBA--------------
<br />2A. DESCRIPTION OF WAsiE 26. CONTAINER TYPE
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />VOL
<br />UN 3291, PG 11
<br />sump ARV(By ContType) QTY CF
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11 -A
<br />TB14 44 Gal Tub(Bio), 2 11.8
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />0
<br />UN 3291, PG 11
<br />__
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />DELIVERY DOCUMENT 1: POFRBS0511
<br />UN 3291, PG 11
<br />-------------
<br />-
<br />LU
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />DELIVERED ITEMS: 2
<br />Z
<br />UN 3291, PG 11
<br />TOTAL
<br />UJI
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />QTY
<br />ITEM
<br />LIN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />T014 44 Gal Tub(B10), C 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 Cu I
<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 Signaturef7
<br />Date
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone
<br />U.1
<br />Applicable Permit Numbers:
<br />0
<br />(L
<br />Z
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described' b ove-,
<br />Print/Type Name Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
<br />Phone
<br />cm Uj
<br />UWJ !R kx
<br />Applicable Permit Numbers:
<br />�2 r3 W
<br />W I
<br />a. 20
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<br />'n UJ <
<br />INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />WApplicable
<br />Permit Numbers:
<br />�-25W
<br />CrIll-i
<br />020
<br />RZ <
<br />(n W
<br />INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />ZQ.
<br />P =
<br />93
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />3
<br />❑ 8A. Designated Facility: 88. Alternate Facility: 8C. Alternate Facility: El 81). Alternate Facility: � 8E. Alternate Facility:
<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />Z3 a
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<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />�9
<br />2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />-2
<br />E aVernon,
<br />CA 90023 San Leandro, CA 94577 Fresno, CA 93722 North Salt Lake,
<br />(801) 936-1555
<br />UT 84054
<br />Z :.! E'
<br />UJ J's f.
<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
<br />E
<br />MWTS Permit # P-6 MWTS Permit # TS/OST-25 Treatment by incineration
<br />E
<br />UJ ��
<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 />4
<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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