|
®
<br />o Stericycle, IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-234-0051 j
<br />F}-
<br />i
<br />1. Generator's Name, Address andy TelE one'Number
<br />Be. Alternate Facility:
<br />g
<br />8D. Alternate Facility:
<br />8E. Alternate Facility::8A
<br />pp s
<br />SERVICE RECEIPT
<br />�.
<br />-...
<br />---------------
<br />ACCOUNT 11: 6076382-001
<br />E
<br />U
<br />Autoclavable Treatment
<br />T.
<br />CUSTOMER NAME Sutter Gould/Stockton Me
<br />Incineration Treatment
<br />..t1 s
<br />SERVICE DATE: 06/01/07 10:40:00 AM
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />DRIVER ID: BSi
<br />LLL g
<br />2775 E. 26th Street
<br />1345 Doolittle Drive, Suite C
<br />---------------
<br />90 North 1100 West
<br />F-
<br />SHIPPING DOCUMENT 11: RDFROO5701
<br />----------------
<br />San Leandro, CA 94577
<br />Fresno, CA 93722
<br />CUSTOMER NUMBER ?"��.�-�"'�('5-••i,f!??. GENERATOR'S REGISTRATION #
<br />TOTAL CONTAINERS COLLECTED: 4
<br />Z
<br />Lu
<br />(323) 362-3000
<br />(510) 562-1781(559)
<br />TOTAL VOLUME COLLECTED: 23.6 CU FT
<br />(801) 936-1555
<br />Class V Incineration
<br />2A. DESCRIPTION OF WASTE 213• CONTAINER TYPE
<br />______________-
<br />MWTF Permit # TS -31
<br />MWTS/OST Permit # TS/OST-22
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, 5 , - 90 a�aT a
<br />Tip_:^ 2 i, : �, �k `�''
<br />0OA0013 T014 0OA0012 TB14 (juAO(;; I 16l ,
<br />MWTS Permit # P-6
<br />UN 3291, PG II �
<br />0OA0010 T814
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, 'P�,' t- - 7 7i, ;; A4 r 3 : :,
<br />TREATMENT FACILITY. I certify
<br />that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />t
<br />UN 3291, PG II
<br />wastes in accordance with the requirement outlined in that authorization.
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, $V2 i 4 � 4 i"a.,„ S x r I e i r" c' >,�g3 �-;
<br />UN 3291, PG �----'
<br />VOL
<br />SUMMARY(By ContType) QTY CF
<br />O
<br />n
<br />Date
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, Mg
<br />UN 3291, PG II
<br />TB14 44 Gal Tub(Bio), 4 23.6
<br />Cu
<br />W
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, 9.'P:;.; — 20 Gii.1 Tub a`�u� €nt ^• 't ou
<br />------ I _ -
<br />Z
<br />W
<br />UN 3291, PG 11
<br />DELI VERY DOCUMENT 4: POFROO5701
<br />Cu
<br />fR
<br />!J
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2, aa.. y.
<br />rr.:-F�... ._ k2 .J '. ,A,�' ¢=T.1 _.e'y.
<br />" `
<br />______ __. _.
<br />..: .'
<br />UN 3291, Pc II
<br />TOTAL DELIVERED ITEMS: 3
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG 11
<br />ITEM QTY
<br />Cu
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II I
<br />TB14 44 Gal Tub(Bio), C 3
<br />Cu
<br />t"�¢sfi$"#3RS:.6tit#at�`�'E&wtri
<br />Cu
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately
<br />Cu
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded; and.
<br />are in all respects in, prD condition for transpo according to.applicable international and national governmental ref
<br />t �s �
<br />;
<br />,
<br />X
<br />Printed/Typed'
<br />Name Signature
<br />�wzs w
<br />W
<br />4. TRANSPORTER 1 DRESS:
<br />.e r:td"" 3'.'-, ig§. �- e -
<br />Phone #.
<br />}�
<br />g
<br />13
<br />Y�hJrK
<br />Applicable Permit Numbers:
<br />Q Op
<br />_ CO
<br />a Q
<br />;�
<br />TRANSPORTER-CERWIaCATION: 46bi@pyt of medical waste as described` hove
<br />��yf
<br />F-epp
<br />Print/Type Name - Signature . '` - 4", '
<br />Date
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />N W
<br />w a W
<br />r
<br />Applicable Permit Numbers:
<br />ij3Lu
<br />J
<br />adz
<br />Z M=
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />�z
<br />~
<br />Print/Type Name Signature
<br />Date
<br />M W
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #: �'i
<br />w ¢_
<br />Applicable Permit Numbers:
<br />W
<br />QUJ
<br />OZO
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Z
<br />aZ
<br />z
<br />Print/Type Name Signature
<br />Date
<br />r
<br />7. DISCREPANCY INDICATION
<br />F}-
<br />Designated Facility:
<br />❑
<br />Be. Alternate Facility:
<br />8C.,Alternate Facility:
<br />8D. Alternate Facility:
<br />8E. Alternate Facility::8A
<br />gni
<br />5
<br />�.
<br />-...
<br />E
<br />U
<br />Autoclavable Treatment
<br />Autoclavable Treatment
<br />Autoclavable Treatment
<br />Incineration Treatment
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />LLL g
<br />2775 E. 26th Street
<br />1345 Doolittle Drive, Suite C
<br />4135 W. Swift Avenue
<br />90 North 1100 West
<br />F-
<br />Vernon, CA 90023
<br />San Leandro, CA 94577
<br />Fresno, CA 93722
<br />North Salt Lake, UT 84054
<br />Z
<br />Lu
<br />(323) 362-3000
<br />(510) 562-1781(559)
<br />275-0994
<br />(801) 936-1555
<br />Class V Incineration
<br />MWTF Permit # P-115
<br />MWTF Permit # TS -31
<br />MWTS/OST Permit # TS/OST-22
<br />Permit #91-02
<br />MWTS Permit # P-6
<br />MWTS Permit # TS/OST-25
<br />Treatment by incineration
<br />W o w
<br />TREATMENT FACILITY. I certify
<br />that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />t
<br />received the above indicated
<br />wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name
<br />Signature
<br />Date
<br />LEAVE AT GENERATOR
<br />
|