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00 Staricycle® IN CASE OF EMERGENCY CONTACT. CHEMTREC 1.800-234-0051
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<br />LEAVE AT GENERATOR
<br />1. Generator's Name, Address and Tele 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 />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 0-,
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<br />described above by the proper shipping name, and are classified, packaged, marked and label led/placarded, and
<br />are in all respects in proper condition for transport according to applicable international and nationaLgovrernmental regulations."
<br />A Printed/Typed Name Signature
<br />Date
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone
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<br />Applicable Permit Numbers:
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<br />TRANS PORTERZERTIFICATION: Receipt of medical waste as describedabov"e-1
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<br />Print/Type Name Signaturd
<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 />INTERMEDIATE HANDLER TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Print/Type Name Signature
<br />Date
<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 />F� 8A. Designated Facility: 8B. Alternate Facility: BC Alternate Facility:
<br />El 8D. Alternate Facility:
<br />Ej 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 />North Salt Lake, LIT
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722
<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 MWTS 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
<br />wastes and that I have
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<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />Date
<br />LEAVE AT GENERATOR
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