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MEDICAL WAS RAC/KI�1Q FORM NUMBER
<br /> �•:� Stericycle' IN CASE OP ESI Alii cy (;; ACT:CCHEMTREC 1400.424.9300 s#itri�o�R � D i�pil@ jj>�bt •o3.21 •NOCA
<br /> CUSTOMER NO* 21132
<br /> `1Generrator'i1aUdrosOAd Telephone Number
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<br /> 3112 S F•T"tIRhittaT AV 9/330/2022
<br /> lODI , CA9524IO0 3340 ( 209) 369- 541u
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<br /> CUSTOMER NUMBER GENERATOR% REGISTRATION N
<br /> 2A. DESCRIPTION OFWASTE 28, I { , 1it .- fF1j0 ) TF' 'i4 ' P NTAtNERCTIPE` ICtCIDt' { M ) ,Ir' G41 it 9Ct ;Np ,O,I ;ti 2D. VOLUME
<br /> UN3291 , Regulated Medical Waste, n.o.s., GOtt7 �►fNERS
<br /> 6.21 PGII TC2 + - ( Eio1 11=' •15- ( (;Ahl I M5dC'1• u4mo ) 20 Gni , Tu (2207 cuff . ) Cu Ft,
<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 612, Poll TE 104Biol 1 `{<lr' - ( C': IiDttiDl T14 !341nC•irl@f .ir31 ^ 7 Gal . Tub (4 . 9 C: u L ) Cu Ft.
<br /> W UN3291 , Regulated Medical Waste, n.o.s.,
<br /> p 6.21 PGII \1y011 :2�4Etir. 1 ^ CkMl3- (Chertiol 111/:!4 VP ianrtl ) X13 r,; al . Tub ( 5 . 7 ' ti 1J46 # 6Cu Ft.
<br /> IMPUN32911 Regulated Medical Waste, n.o.s.,
<br /> 6.21 PGII KR (Bin ) GO , Corrucial_ d Box (4 . 32 Cuft. ) Cu Fl.
<br /> W UN3291 Regulated Medical Waste, n.o.s.,
<br /> W 6.2, 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 /> 6.2, PGII Cu FL
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s.,
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<br /> 3. Generator'• Cadiflcatione "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► —i rJ Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br /> are in all respects In proper condition for transport according to applicable International and national governmental regulations"
<br /> I tIn , Signature r '
<br /> 4. TRANSPO E f "ADORESS:" ' j J t1ic3 IS Ll1t'otlil l - * illilitt' 1if Phone #0 ff
<br /> 78751R A } ridgeford Rd6 Applicable Permit NUmuii�': �
<br /> TRANSPORTER FICATIOlk' s Ript of medical waste as described abave,
<br /> Print/Type Name rt 1rA Signature Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone M:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PdnVType Name Signature Date
<br /> h S. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone 11:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> s
<br /> Printrrype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> RYA LISE
<br /> V 6Ey_, ) Ell.A6rh iiMyetclltty;(lndneratc1r) p EC}A6?natkFkII(Iy fA1jtU1j1E era) MilD:AthMItB` f7C1111yI , Int: -
<br /> � . 4 f5 R. \ �-� rltictErartJ Rd . •_ J N . t , I. o t r _ 277 ., Er 2661 �r, i _ . � G�ra � Iclaiie r;t. Rutit=
<br /> T • k , � ,. l , UT 11^. q t rn - n , A OM 0r _ 1t7, O1`: 7:�r ,.
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<br /> ILI � $ (2a'2 )� ?' rj 1 �Y 022 ( 801 M ]11 " 1171 (806 )78423 tI ? 2 pro )39 -r89r
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<br /> eC TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> 1- received the above indicated wastes in accordance with the requirement outlined In that authorization.
<br /> Print/Type Name Signature Date
<br /> I
<br /> ORIGINAL
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