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<br />1. Generator's Name, Address and Tel one Number
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<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION#
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 110-
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in pr,?Porcondition for transport according to applicable international and national glp)(ernmental regulations." I
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<br />Printed/Typed Name Signature J-
<br />Date
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone #:
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<br />Applicable Permit Numbers:
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<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above`
<br />Print/Type Name Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
<br />Phone #:
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<br />Applicable Permit Numbers:
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<br />Date
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<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #:
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />-1 F❑ 8A. Designated Facility: 8B. Alternate Facility: 8C Alternate Facility: 8D. Alternate Facility:
<br />F-1 8E. Alternate Facility:
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<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
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<br />2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
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<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 North Salt Lake, LIT
<br />84054
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<br />(801) 936-1555
<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 />MWTS Permit # P-6 IVIWTS Permit # TS/OST-25 Treatment by incineration
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<br />TREATMENT FACILITY- I certify that I have been authorized by the applicable state agency' to accept untreated medical wastes and that I have
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<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
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<br />Print/Type Name Signature
<br />Date
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