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<br />. Stericycle ® IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-234-0051
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<br />1. Generator's Name, Address and T4
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<br />CUSTOMER NUMBER
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<br />GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />REGULATED MEDICAL WASTE, 6.2,
<br />CONWNERS
<br />n.o.s.,
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<br />UN 3291, PG II
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<br />UN 3291, PG II
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<br />TOTALS ®
<br />3. Generator's Certification: hereby declare that the contents of this consignment are fully and accurately
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<br />are in all respects in proper condition for transport according to applicable international and national�governmental regulations."
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<br />4. TRANSPORTER 1 ADDRESS: Phone #:
<br />} H Applicable Permit Numbers
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<br />a 4 TRANSPORTER GERTIFICATIO . Receipt of medical waste as described above r° -t
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<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
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<br />Wa Applicable Permit Numbers:
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<br />Z W s INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTF..R 3 ADDRESS: Phone #:
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<br />w Q Applicable Permit Numbers:
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<br />zw= INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />7. DISCREPANCY INDICATION
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<br />=3 ❑ 8A. Designated Facility: El 8B. Alternate Facility: 1M.8C-Alternate Facility:❑ SD. Alternate Facility: El 8E. Alternate Facility:
<br />= d - Autoclavable Treatment Autoclavable Treatment `Autoclavable Treatment Incineration Treatment
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<br />2-21 Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />u g 2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />F- d E Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722 North Salt Lake, UT 84054
<br />Z (801) 936-1555
<br />W (323) 362-3000 (510) 562-1781 (559) 275-0994 Class V Incineration
<br />v - MWTF Permit # P-115 MWTF Permit # TS -31 MWTS/OST Permit # TS/0ST-22 Permit #91-02
<br />L- MWTS Permit # P-6 MWTS Permit # TS/0ST-25 Treatment by incineration
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<br />LU o m TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />IXreceived the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />LEAVE AT GENERATOR
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