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<br />Mo
<br />®® Stericycle'
<br />• rsw.crr~rseoe u .:hum -
<br />_aZzo'°N W �Z-YZIOZ^ytil 'any—au�il pania°a�
<br />ALvv^*rEri+fPAJ8 r ME�Ncr C�TACT.CHEIttTREC i4MA24-M � MDLzE4)llo�.sro
<br />CUSTOMER NO.
<br />1. Generator's Name', AddreSS and Telephone Number III � 4 III 111111111H11111111
<br />AWN :
<br />FCIMM VALLEY G.A=11
<br />15-17 MCR VX3MR DRIVE
<br />S'POcKI'Oir, CA 95214- 3119 .
<br />(249) 957-9539 12/12/2011
<br />Cesmuen Nuss"A 6064005-002 penaw,roae RtarsnunoH e
<br />2A. DESCRIPTION OF WASTE 2B, CONTAINERTYDE
<br />UN3291,Regulated Medical Waste. n,o.s.. Sa57 - 90 Gal Tub (Oio) (12 Cu tit)
<br />6.2, PGII
<br />UN3291,Regulated Medical Waste,n.e,a, TB49 - 37 GAL Tub (bio) (4.9 C4 ft)
<br />6.2, Felt
<br />OU 2 FGI, Regulated MediMl Wade, n.o.s., T1314 - 44 (�1 TUMB1.41 A) (5.9 Cu it)
<br />d UN3291, Regulated Medical Waste, n.o.x.,
<br />A.2, Pril
<br />W UN3291, Regulated Medical Waste, n.a.s_, TS15 - 20 Gal 'YUb Pd ) 6 Cu C
<br />Z 6.2, PGII
<br />UN3291,Regulated Medical Waste, n,o.s., T711§ - 20 Gal Tub (Chemo) (2.7 cu ft)
<br />6.2, Pali
<br />UN3291 Regulated Medical waste, n,o
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o,s..
<br />6.2. PGII
<br />Pharmaceutical Wast.
<br />3- Generator's Certlllcatlon:'I hereby declare that the contents of this consignment aro fully and accurately
<br />TOTALS ►
<br />described above by the piper snipping flame, and are classified, packaged matin and labetlad/placarded, and
<br />are in all respects in proper condition for transport according to mollcatile Internalional and national governmental regulations.'
<br />i -i
<br />i PrintoMypetl Name � • 1 K-+ w Signature
<br />2C. NO, OF
<br />CONTAINERS
<br />M
<br />Q
<br />4. TRANSPORTER 1 DRass: Phone e' 0�v�,► y sed.
<br />W. a�tericycle, Inc:. ❑ TI, L, is a ugh S)ai Pme-ttt mb9>d:
<br />4135 West Swift Ave.e. appllcaVe Permit Nusaule Req# 3400
<br />� � Fresno, Ca 93721.
<br />m
<br />a q TRANSPORTER CERTIFICATION' Receipt of medical waste as described above,
<br />Pritur ype Name t `- Signature Date
<br />as IM
<br />6 INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADURGSS' I Phone 4:
<br />QApplicable
<br />//J A.
<br />Permit N%Jmbers!
<br />11c. attamne Fact 1.
<br />Inc -Autodvo
<br />Dooms
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION' Receipt of medical waste as described above.
<br />4 35 W r AVE
<br />-
<br />PrinVrypoName Signature
<br />Date
<br />2775 STREET
<br />VEPI,10N, CA 901123
<br />FRESNO,CA 93722
<br />(559) 275 - 1121
<br />6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS:
<br />Phone p:
<br />CC
<br />C
<br />(373) 362 - 3000
<br />Applicable Permit Numbers:
<br />$
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION- Recelpi of madleal matt* as described above,
<br />T9311!' MT25
<br />TSIOST 26
<br />Print/Type Name SIgnatura
<br />Date
<br />7. DISCREPANCY INDICATION T(dr15�9rr8i( containers, CU Q to _ Norm Salt Lake, UT
<br />I b' /
<br />aA, t)eslgn$W Feetlity:
<br />ve
<br />eSWF
<br />//J A.
<br />08. Alternflte FacQW!
<br />e Ino nerallon
<br />Ste90
<br />11c. attamne Fact 1.
<br />Inc -Autodvo
<br />Dooms
<br />u BD. Attarnds Facility:
<br />Inc -AUtodwe
<br />W6'I"f'1
<br />4 35 W r AVE
<br />NOORRTH 100 W W►T
<br />1345 Pave ate C
<br />San Leandro, CA 24671
<br />2775 STREET
<br />VEPI,10N, CA 901123
<br />FRESNO,CA 93722
<br />(559) 275 - 1121
<br />NORTH SALT LAKE CITY, UT
<br />(M 1) 936- 1555
<br />(5 10) 562 - 2177
<br />(373) 362 - 3000
<br />5MST22
<br />3A-448JA-35
<br />T9311!' MT25
<br />TSIOST 26
<br />r.,,...
<br />TREATMENT FACILITY: I certify that i have been authorized by the applicable state agency to accept untreated medica) Wastes and that I have
<br />received the above indicated wastes in accordance with the requirement outlined
<br />in that authorization.
<br />Printlrype Nomr E i 2 2011
<br />Sionaturo
<br />naso
<br />rptFls f tStlP�e 2011 ORIGINAL.
<br />O VO L d 26£88M0Z << L�: � L� L -80 - Z L U
<br />//J A.
<br />rptFls f tStlP�e 2011 ORIGINAL.
<br />O VO L d 26£88M0Z << L�: � L� L -80 - Z L U
<br />
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