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MEDICAL WASTE T G C�RNI'•NDMt
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<br />® Stericycle a IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-234-0051
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<br />cal received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />1. Generator's Name, Address and Telephone Number
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<br />CUSTOMER NUMBER __.. _.... GENERATOR'S REGISTRATION# - .:-
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<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />REGULATED, MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
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<br />CONTAINERS
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PGII
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<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 ► C
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<br />4. TRANSPORTER 1 ADDRESS: Phone#
<br />Applicable Permit Numbers:
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<br />TRANSPORT r I'TIFICATayI eceipt of medical waste as describe a ' Ge. ;jl ,
<br />Print/Type Name Signature Date -
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: 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/T e Name
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<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS. 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 Date
<br />7. DISCREPANCY INDICATION
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<br />❑ 8A. Designated Facility:
<br />8B. Alternate Facility:
<br />!,i}C ,Alternate Facility:
<br />8D. Alternate Facility:
<br />8E. Alternate Facility:
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<br />Autoclavable Treatment
<br />Autoclavable Treatment
<br />Autoclavable Treatment
<br />Incineration Treatment
<br />Stericycle, Inc.
<br />2775 E. 26th Street
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />90 North 1100 West
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<br />1345 Doolittle Drive, Suite C
<br />4135 W. Swift Avenue
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<br />Vernon, CA 90023
<br />San Leandro, CA 94577
<br />Fresno, CA 93722
<br />North Salt Lake, UT 84054
<br />936-1555
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<br />323 362-3000 '
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<br />(510 562-1781
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<br />(559) 275 0994
<br />(801)
<br />Class V Incineration
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<br />MWTF Permit # P-115
<br />MWTF Permit # TS -31
<br />MWTS/OST Permit # TS/OST-22
<br />Permit #91-02
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<br />MWTS Permit # P-6
<br />MWTS Permit # TS/OST-25
<br />Treatment by incineration
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<br />TREATMENT FACILITY. I certifv
<br />that I have been authnrizpri
<br />by the annIinahlp ctatp anpnr v
<br />tn arrant i intrnnfaH marfl—I --f—
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<br />cal received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />
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