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HQU rl= <br /> •�e� Stericycle <br /> e! Regulated Waste Shipping Document <br /> DATE �- IA'`M IIERE <br /> DOCUMENT NO.: 11111111111111111111111111111111111111111111TRACK" <br /> Al <br /> Medical Waste Tracking System <br /> IIN H�:JF�II 11i1�i;Mi�44"`� <br /> $ilIpp!N[, U;";UHtNI <br /> Name <br /> _ ;M,rias%a , r'iI(iNF. J-i51)il �3C <br /> CCirJNI a- 5u;1477 Oct <br /> Address r4 CAiI� REHAB <br /> $iilr fUR'J # <br /> city State Zip Emer <br /> Phone !H)Regulated Medical Waste, 6.2, UN3291, PGII <br /> • ! <br /> hi,auAIFU HfliiCAt WASTE <br /> AUTOCLAVABLE WASTE h Uh3?y; PhII <br /> Cont Quantity Cont Quantity IU'Al MUCH) 4LNT�iNER': <br /> TOTAL IC-:1W ?.C144(t :;;"'j" N� <br /> Type P/u Del Type P/U Del <br /> T657 SH05 :ir r, luCt I'?�F Cllt;f <br /> TB49 SH06 a,oON r:3zl <br /> TB35 SH07 <br /> TB24 SH08 <br /> TB21 SH09 „ .EO ANO ANF <br /> TB14 SH11 :II.NSIVI,I�I;,N <br /> �� ,;,i � . ,. ;II r f{El;il;AI iON•. .a i.. <br /> TB06 SH59 �:MEti, �I;r,i,�,�Uhial ulN <br /> ST75 SH60 <br /> ST32 SH91 <br /> SH03 BX99 <br /> �1 <br /> GENERATOR CERTIFICATION: This is to certify that the above named materials are properly classified, described, pack; r lition for <br /> transportation according to the applicable regulations of the Department of Transportation. <br /> `' dUIHONIIt_D >ICNA116iF <br /> Print Name G6nerator's Signature <br /> NON-D.O.T. REGULATED ■ <br /> FG57 R :u„, ul �Iu ITENS I <br /> XM99 P <br /> YI't UI'. ItiPE ClY 1'r'Pt ui'i <br /> TD86 F <br /> F 1821 1 <br /> TRANSPORTER ` <br /> Stericycle, Inc. ❑ Stericycle, Inc. E] Stericycle, Inc. <br /> 28161 N.Keith Dr. 28161 N.Keith Dr. 11875 Whiterock Road <br /> Lake Forest, IL 60045 Lake Forest, IL 60045 Rancho Cordova,CA 95742 <br /> (323)362-3000 (323)362-3000 (916) 985-5506 <br /> Haz.Hauler,Reg,#3400 Haz.Hauler, Reg.#3400 MWTS Permit#34-6-P <br /> Authorized Signature Dae Authorized Signature Date Initial Date Received r <br /> INCINERATION WASTE <br /> AUTOCLAVABLE WASTE TREATMENT & INCINERATION WASTE TRANSFER DESTINATION <br /> Stericycle, Inc. F-1 Stericycle, Inc. Stericycle, Inc. <br /> 4135 W.Swift Avenue 1345 Doolittle Drive,Suite C 90 North 1100 West <br /> Fresno,CA 93722 San Leandro, CA 94577 North Salt Lake, LIT 84 <br /> (559)275 0992 (510)636-9502 (801)936-1555 <br /> MWTF Permit#10-43-P MWTS Permit#19-23-P - Class V Incineration <br /> Treatment by autoclaving MWTF Permit#37-48-P Authorized Signature Date Permit#91-02 <br /> MWTS#10-8-P #37-25-P P-132 Treatment by incineratir <br />