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r•ZIN CASE O0p
<br /> F EMERGENCY CONTACT: CHEWMEC 14 •424-9309 MEdtCA STANDARD
<br /> ND RTE TRA SKI00Q FOR�NUM9Eq
<br /> SOP Stericycle' Rof.Ite ## 706 - 17 CUSTOMER NO. 21132 IVIDTKOOOVI 0
<br /> I . Generator's Name, Address and Telephone NumberATTN ' E)aic Crowley i Jill
<br /> TOKAY li YSI oDAVITA � 201fi� A I 1 { I � I � If ! 111 Jill
<br /> 11
<br /> 312 'S FAIR11 ONTAVE 0/26/2022
<br /> LOD] , CA95240-3040 6 , 20901) 369-54, 10'
<br /> 6053303 001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRAnON 0
<br /> 2A, DESCRIPTION OF WASTE 28• CONTAINER TY FF."
<br /> 2C. NO, OF 20. VOLUME
<br /> H 23PGIU291I Regulated Medical Waste, n.a.s., T - (ialO ) T P '14-(Path ) TY14 -(Incinerate ) 44 Cal . T Ia�iE
<br /> Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o,s., TP29 - (Bio )_w,_„_TP15-( Path)- TY15-(Cherno ) ,,,_,_ 20 Cnal . Tu (2 .7 CUR . )
<br /> H.2, PGII Cu Ft.
<br /> UN3291Regulated Medical Waste, n,o.s., n_ Ch
<br /> 6,2, PGII TEI ►-(13io ) � TY� � ( erl� a )_ T (QOi-( Incinerate ) �7 Coal . Tub (4 . 2 Cu . ) Cu Ft.
<br /> RUN3291 RegulatedMedlcalWaste, n.o.s• YS/1�43-( Ffio ) C1/�/a •I_ (Chemo )_ WX43,am Phanrn dW Gal , u � R 7 _' if . )
<br /> M 6.2, PGII ( ) - - - - ( ` ' Cu Ft,
<br /> W UN3291 Regulated MedicaIWaste, n.o.s„ ISPPia Gal . Corrugated Box (4 . 32 Cuft. )
<br /> rZ 6.21 PGII ( ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s• ,
<br /> 621 PGiI Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s„
<br /> 6.21 PGII Cu Ft,
<br /> UN3291 Regulated Medical Waste, n.o.s„
<br /> 6.2, PGiI Cu Ff.
<br /> UN3291 Regulated Medical Waste, n.o.s•,
<br /> 621 PGII u FI.
<br /> 3. Generator's CertHicatlon: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► i Cu Ftt
<br /> described above by the proper shipping name, and are classified, packaged, marked and labeiled/piacarded, and
<br /> are in all respects in proper condition for transport according to applicable international and national governmental regulatlons"
<br /> Print Name w ? SignatureOff Date
<br /> 4. TRANSPOPER, 1 ADDRESS: Phone N:
<br /> I ( 9) 2'94J10-144
<br /> .) cr'tcycle , Itic . This Is a T(l1#01.1g l Shiplllwtlt Applicable Permit Numbers:
<br /> 7075 R A Brlityeford Rd . TSVOST Oft
<br /> a R Stockton , CA 95206
<br /> a TRANSPORTER FICATION: e(; ,, 6)9
<br /> t of medical waste as descn 1
<br /> Print/Type Name (_.-It e7 l _ _ Signature . �n pate 4 � W-
<br /> So INTERMEDIATE HANDLER 2 / TFIANSPORTER 2 ADDRESS: Phone N:
<br /> a � Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> i 6. INTERMEDIATE HANDLER 3 / TPANSPORTER 3 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> W -
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> GONE Print/Type Name — --- - Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> l
<br /> r BA: DNlgnaled Faciitty: a8. Alternate Feoility: • • E] 6C. Akemale Facility: BD, Attemrtb Facility:r5tericycle ; itiv: (Autoclave ) 5tedclicle , inc. . (Inrdnerator) Stericycle , inc. (Autocl�te) Covanta Marlon , Inc
<br /> d 7d75 RA Bridgeford Rd. 00 No Foxhorc Drive 2776 E . 26th Wt, 4660 Brooklake road NE
<br /> > ATJ61 :Q , N&J208 North Walt Lake , UT 84054 Vernon , CA 80050 Brooks, OR 87306
<br /> W 1 (2G9)294 - 711 # (801 )938- 7171 (B 130 % 7834422 (506 ) 393 -0890
<br /> T5/05T- 00
<br /> 3H-998/tA-'3c� Permit # 364Q . . ;-. ; ;: j. ir 1*Aa ? I
<br /> pill TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the above indicated wastes in accordance with the requirement outlined in that authorization .
<br /> Iln Pr'nt/Type Name Signature Date
<br />
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