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®6 Stericycle
<br />lip,
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-234-0051
<br />---------------
<br />SERVICE RECEIPT
<br />----------------
<br />I t Fa. ACCOUNT #: 60 -001
<br />CUSTOMER NAME Sutter Gould/Stockton Me
<br />s _ SERVICE DATE. 06/08/07 12:46:00 PM
<br />DRIVER ID: BS1
<br />---------------
<br />SHIPPING DOCUMENT # MDFROO582V
<br />---------------
<br />TOTAL CONTAINERS COLLECTED 5
<br />-" TOTAL VOLUME COLLECTED: 29.5 CU FT
<br />---------------
<br />1. Generator's Name, Address and TeleTione Number
<br />T.
<br />CUSTOMER NUMBER
<br />GENERATOR'S REGISTRATION #
<br />2B. CONTAINER TYPE
<br />-.. 4 G%a_. `'.A y.L. ,,, (5 .9 y.ou ft)
<br />CIIA
<br />0OA001L TBA 0OA001K TB14 DOA001J TB14
<br />OOA001M TB14 OOAOOIN T814
<br />--------------
<br />VOL
<br />SUMMARY(By ContType) QTY CF
<br />T814 44 Gal Tub(Bio), 5 29.5
<br />DELIVERY DOCUMENT #: POFROO582V
<br />---------------
<br />TOTAL DELIVERED ITEMS: 5
<br />ITEM QTY
<br />TB14 44 Gal Ttb(Bio), C 5
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTA I
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and --------- TEAR HERE ---
<br />are in all respects in '
<br />oper condition for transport according to ,applicable international and national governmental regulation)
<br />Printed/3yped Name S g a re Date %-.--'
<br />4. TRANSPORTER 1 ADDRESS: --i Phone #: ? a t1 !
<br />Applicable Permit Numbers:
<br />4135 Uest Q o 13- Fresrio,Ca d^ f TI's 3. t T� r iut h .Sstt rA..IaerIt
<br />U) f �.
<br />EE
<br />a TRANSPORTER CERTIFICATION;: Receipt of medical waste as described above. }
<br />Print/T a Name-
<br />;k" -,t -
<br />YP Signature ` / Date
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br />N w
<br />ozi W s Applicable Permit Numbers:
<br />0
<br />Lu
<br />g
<br />Z0:
<br />wi INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />~ Print/Type Name Signature Date
<br />FW- 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phon,, ,g;IX
<br />w 4 Ix w Applicable Permit Numbers:
<br />0
<br />W
<br />J
<br />Z w= INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />az
<br />�— Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION fed to$
<br />❑ 8A: Designated Facility: 8B. Alternate Facility: U 8C. Alternate Facility: El 8D. Alternate Facility: BE. Alternate Facility:
<br />', g Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />V = Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />3 2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />IL 3 3
<br />®E North Salt Lake, UT 84054
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722
<br />Z �E (323)362-3000 (510)562-1781 (559)275-0994 Class Incineration 5
<br />iI 6 MWTF Permit # P-115 MWTF Permit # TS -31' MWTS/QST Permit # TS/OST-22 Class V Incineration
<br />d Permit #91-02
<br />MWTS Permit # P-6 MWTS Permit # TS/OST-25 Treatment by incineration
<br />yqj o TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />L received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />LEAVE AT GENERATOR �..�.x . ,:.rte • ;.- ��, ,: �,
<br />2A. DESCRIPTION OF WASTE
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />O
<br />UN 3291, PG II
<br />QREGULATED
<br />MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />W
<br />REGULATED MEDICAL WASTE, ' n.o.s., 6.2,
<br />IZ
<br />UN 3291, PG II
<br />REGULATED • MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />REGULATED MEDICAL WASTE, n.o.s., 6.2,
<br />UN 3291, PG II
<br />�h�rrrrac:�.attt�'Ei tJsrs�s
<br />GENERATOR'S REGISTRATION #
<br />2B. CONTAINER TYPE
<br />-.. 4 G%a_. `'.A y.L. ,,, (5 .9 y.ou ft)
<br />CIIA
<br />0OA001L TBA 0OA001K TB14 DOA001J TB14
<br />OOA001M TB14 OOAOOIN T814
<br />--------------
<br />VOL
<br />SUMMARY(By ContType) QTY CF
<br />T814 44 Gal Tub(Bio), 5 29.5
<br />DELIVERY DOCUMENT #: POFROO582V
<br />---------------
<br />TOTAL DELIVERED ITEMS: 5
<br />ITEM QTY
<br />TB14 44 Gal Ttb(Bio), C 5
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTA I
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and --------- TEAR HERE ---
<br />are in all respects in '
<br />oper condition for transport according to ,applicable international and national governmental regulation)
<br />Printed/3yped Name S g a re Date %-.--'
<br />4. TRANSPORTER 1 ADDRESS: --i Phone #: ? a t1 !
<br />Applicable Permit Numbers:
<br />4135 Uest Q o 13- Fresrio,Ca d^ f TI's 3. t T� r iut h .Sstt rA..IaerIt
<br />U) f �.
<br />EE
<br />a TRANSPORTER CERTIFICATION;: Receipt of medical waste as described above. }
<br />Print/T a Name-
<br />;k" -,t -
<br />YP Signature ` / Date
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br />N w
<br />ozi W s Applicable Permit Numbers:
<br />0
<br />Lu
<br />g
<br />Z0:
<br />wi INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />~ Print/Type Name Signature Date
<br />FW- 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phon,, ,g;IX
<br />w 4 Ix w Applicable Permit Numbers:
<br />0
<br />W
<br />J
<br />Z w= INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />az
<br />�— Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION fed to$
<br />❑ 8A: Designated Facility: 8B. Alternate Facility: U 8C. Alternate Facility: El 8D. Alternate Facility: BE. Alternate Facility:
<br />', g Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment
<br />V = Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />3 2775 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West
<br />IL 3 3
<br />®E North Salt Lake, UT 84054
<br />Vernon, CA 90023 San Leandro, CA 94577 Fresno, CA 93722
<br />Z �E (323)362-3000 (510)562-1781 (559)275-0994 Class Incineration 5
<br />iI 6 MWTF Permit # P-115 MWTF Permit # TS -31' MWTS/QST Permit # TS/OST-22 Class V Incineration
<br />d Permit #91-02
<br />MWTS Permit # P-6 MWTS Permit # TS/OST-25 Treatment by incineration
<br />yqj o TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />L received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />LEAVE AT GENERATOR �..�.x . ,:.rte • ;.- ��, ,: �,
<br />
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