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Stericycle' IN CASE OF EMERGENCY CONTACT. CHEMTREC 1 .5001244301)
<br /> Roll 703 .12 CUSTOMER N0, 21132 MDTK001 ERP
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATDIA Eric Crowley
<br /> TOt�AY Ci( ALY`�5 ;.:-L�A`JITA01G
<br /> 3412 G; FAIRMONT AVE 2/23/202 '
<br /> LO )Ir DA 95240- 38G40 (209) 369-5413
<br /> CusTorsER Nil 6053303- 001 GENERATows REoisnunoN 0 `
<br /> 2A, DESCRIPTION OF WASTE 281 CONTAINER TYPE 2C. NO. OF 200 VOLUME
<br /> UN3291, Regulated Medical Waste, n,o.s., CONTAI Rs
<br /> 82 PGII T (t31a�TPd:s(P ) _ _TCa3 (Ch)�TJg3(Ph)T �#3t3arubt5.75CUFt) SI ' S Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.s., TH31 (@la�TP•31 (Pd),_„_,TC31 (Ch)_, -7Y, ,31 (Ph),_,_,31Garrub(b . laCurt •,t
<br /> 6.21 PGII Cu Ft.
<br /> M UN3291 , Regulated Medical Waste, n.o.s., KRgpErin X ( Pharrl Corrugated Sox (4 2)
<br /> 0 6.2, PGII
<br /> ♦ Cu Ft.
<br /> p UN3291, Reguaaed Medical Wasts, nog., RX CAL/CT Gasketed Sharp Cont. ( CuFt)
<br /> Ot: 8.2, PGit Poll Cu Ft•
<br /> W UN3291 , Regulated Medical Waste, n.o.s., H GALIOT Gasketed Sharp Cont , ( CuFt)
<br /> W8.2, PGII Cu Ft.
<br /> us UN3291, Repuisted Medical Waste, n,o,s„
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 , Regutsted Medical Waste, n.o,a.,
<br /> 6.2. PGII
<br /> Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n,o.s„
<br /> 8,21 poll Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Ft.
<br /> S. Garmator'a CartNlcation : 01 hereby declare that the contents of this consignment are fully and accurately TOTALS 1111� Q S Cu Ft.
<br /> deecribed Above by the proper shipping name, and are classified, packaged, marked and labelledlplacardad, and
<br /> are in all respects in proper condition for transport according to applicable intematlonal and national governmental regulations,"
<br /> XNwomyped Karroo liftI
<br /> OC 4. TRANSP9M1 D
<br /> 7875 R A Br eford Rd . T( us is t'I t i� hi!r�trPr�ah( ► Applicable Pe�1j1 &#W
<br /> Stockton , CA 95206 DTSC - Haz Waste
<br /> nsporter No: 3400
<br /> TRANSPt)RTER � 1TnIF.ICATIOi,�. Rielpt medical weals as descrtL%�%7t t (/u�d Above; Tre `L.Q
<br /> PdnVrype Nome "`� � , Signature Date
<br /> Wool
<br /> 6. INTERMEDIATE HANDLER 2ITRANSPORTER2ADDRESS;
<br /> Phone i«:
<br /> N �
<br /> Applicable Perth Numbers:
<br /> INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PdnUType Nome Signature Date
<br /> a Ly E. INTERMEDIATE HANDLER 3 I TRANSPORTER 3 ADDRESS: Phone #;
<br /> Applicable Permit Numtol
<br /> INTERMEDIATE HANDLER i TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Print/Type Nome Signature Date
<br /> 7. DISCREPANCY INDICATION Transferred (number of containers),
<br /> Af (cubic feet) to:
<br /> Designated Facility: Permit "I VOST 26 Designated Facility: Pamtit TSiOST-154 Designated Fadlky: Permit TSIOST 83
<br /> ENRON
<br /> A StericyclA, Inc. ! (866) 783 7422 2776 g Stericycb, Inc• 1 (866) 783.7422 7875 C Stericyde, Inc, 1 (888) 7113=7422
<br /> East 28th St; RA Bridgeford St. 1551 Shelton Drive
<br /> all
<br /> Vemon, CA 90058 Stockton, CA 95206 Hollister, CA 95023
<br /> I
<br /> Alternate Facility: Permit H1664 Alternate FadYly: Permit 1100001653434 Altemate Facility: Permit SIT 60-01
<br /> il � I D Sterxyde, inc, f (866) 783-7422 E Covanta Marion, Inc. 1 (503) 393-0890 F Stericyde, inc. I (Still) 783.7422
<br /> Zl 3140 N, 7th St. 4830 B=Wke Rd. NE 128 Rex Bryan Dr.
<br /> U n
<br /> Kaas City. KS 66115 Salem, OR 97305 Springhill, LA 71021
<br /> I Q Alternate Facility: Permit 99110103 Alternate Facility Permit # Alternate Fatally Permit k
<br /> G Evil
<br /> Ster)cydA, Inc. 1 (866) 783 188 5815 H Phi: I Pt
<br /> Weldon Springs Rd. Address: Ate: AtE7f c;u
<br /> Clinton, IL 61727 Pool Alternate Facility TreabrmA Date - Place Stamp Above
<br /> V ph
<br /> Designated Facility: I certify that I have been autlwized by the applicable stale apency to accept untreated FlArt U 1 $
<br /> medical waste and that I have received the above indicated waste in accordance with the requirement
<br /> outlined In that auftizatbn, (Printf NameftnaturoNate Recelved or piece stamp to the *Q All
<br /> ORIGINAL
<br />
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