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<br />stericIclea IN CASE OF EMERGENCY CONTACT. CHENITREC 1-800-234-0051
<br />LEAVE AT GENERATOR ;;:fF-ZWA_r_R
<br />1. Generator's Name, Address and Tele one Number 71 � -1 -----------------
<br />SERVICE RE I PT
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<br />r ACCOUNT 11: 6076382-001
<br />CUSTOMER NAMESUTTER GOULD/STOCKTON ME
<br />A i1 Q- 'U': _1 -1 A E SERVICE DATE 05/18107 09:26:00 AN
<br />DR I VER 10: BS1
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<br />5 4 1 SHIPPING DOCUMENT 11: KOFR00552J
<br />-- ----------------
<br />TOTAL CONTAINERS COLLECTED: 6
<br />CUSTOMER NUMBER i` j C, GENERATOR'S REGISTRATION# TOTAL VOLUME COLLECTED: 35.4 CU FT
<br />- - ----------------
<br />2A. DESCRIPTION OF WASTE 213. CONTAINER TYPE 0OA0019 T814 OOA0018 T614 0OA0017 T814
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2, 00A001A T814 00A00113 TB14 OOAOOIC TB14
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, "3 71 1.11 (4 ,::1A, -It
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<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, e 7= X TB14 44 Gal Tub(Bio), 6 35.4
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®TALS 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,groper condition for transport according to applicable international and national governmental regulations."
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<br />4. TRANSPORTER 1 ADDRESS T Phone #: A -
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<br />TRANSPORTER -CERTIFICATION: Receipt of medical waste as described'abiave: Z
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<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #:
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<br />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 />INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />7. DISCREPANCY INDICATION w.,
<br />F] 8A. Designated Facility: 8B. Alternate Facility: E18C. Alternate Facility: 0 8D. Alternate Facility: 8E. Alternate Facility:
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<br />Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
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<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />90 North 1100 West
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<br />2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue
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<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 North Salt Lake, LIT 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 MVVTF Permit # TS -31 MWTS/CST Permit # TS/CST-22 Permit #91-02
<br />MWTS Permit # P-6 MWTS Permit # TS/CST-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
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name —Signature Date
<br />LEAVE AT GENERATOR ;;:fF-ZWA_r_R
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