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•;;• Stericcue' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800.424-8300
<br />Pf ftc "a Q Route 0: 023 — 5 CUSTOMER NO. 21132 MDFROOGVZU
<br />1. Generator's Name, Address and Telephone Number
<br />ATTU e. NEI
<br />GILL MDICAL CENTER loililumm'illl I Hill III =1 1
<br />1617 N CALUrORMA ST
<br />t3 H, CA 95204-- 6117
<br />k (209) 451-9031 9/15/2015
<br />852-001 GENERM MS REGISTRMWN #
<br />26, CONTAINER TYPE
<br />TBOS - 40 Gal Tub (Bio) (5.3 cu tt)
<br />TB49 - 37, "1 Tub (Bi*) (4.9 Cu tt)
<br />TB14 — 44 Gal Tub(Bi*) (5.9 cu tt)
<br />TB21-(Blo)/TP15-(Path)/TY].5-(Chemo)20 Gal Tub(2.
<br />YB31-(Bio)/wp31-(Path)/=31-(Chea®)31 Gal Tub (4.
<br />3-(Bic)/Fw43-(Path)/CK43-(Chemo) Gal Tub(S.7t
<br />KRB - Bioavatems Cardboard Box (4.2 cu tt)
<br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />described above by the proper shipping name, and are dassiffed, packaged, marked and labeiled/plecarded, a d
<br />are In all respects In e proper wndilton for transport according to appirc able international and n al gomme I regulabon� s.'
<br />_ � =Slanatuv"aNam(rli '� �Y
<br />4. TRANSPORTER 1 ADDRESS:
<br />Stericycle, Inc. 0 thisis trough Shipment
<br />a 4138 N. Swift Ave
<br />_ 0. Feeeno,CA 93722
<br />R.
<br />TRANSPORT QRCJERTI ICA 1p f icor waste as de bed
<br />Pdnt/lype No S�natu
<br />S. INTERMEDIATE HANDIER t / TRANSPORTER 2 ESS:
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pr1nUType Name Slanature
<br />C. NO. OF 20. VOLUME
<br />CONTAINERS
<br />Cu Ft
<br />Cu Ft.
<br />Cu FL
<br />Cu Ft
<br />Cu Ft
<br />Cu Ft.
<br />Cu Ft.
<br />(8647P-7422
<br />-7422
<br />It to Permit Nu ers.
<br />hauler Reg# 3400
<br />Phohe #
<br />Applicable Permit Numbers:
<br />Date
<br />ae 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #
<br />HNApplicable Permit Numbers-
<br />fR INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />— Prtnt/Type Name Stgnahcre Date
<br />T. DISCREPANCY INDICATION
<br />Trmforred M, ai R to : North 8d LaW, UT
<br />Preeno, t' CLAVE I
<br />(808'7( CMANNE ORTIZ ±
<br />MA FAILIA UsQ thaLl have
<br />id bove indicated wastes in acro
<br />n'
<br />MR %D°LkRr
<br />M -4 -MIN _,
<br />Stell ycte, Inc.
<br />1551 Sholon DI(Yit
<br />HoNster. CA 95023
<br />(8t "1131.7422
<br />eu. nnemace Facluw-
<br />Stericycle, Inc.
<br />8140 N 71h Street*
<br />Kerins City, K8 66115
<br />(M)783-7422
<br />TSADST-26
<br />authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />r with the requirement outlined in that authorization.
<br />Date
<br />CusTomeR Numnit 611
<br />2A. DESCRIPTION OF WASTE
<br />UN3291, Regulated Medical Waste, n.o a,
<br />6.2, PGII
<br />UN3291, Regulated Medd Waste, n os.,
<br />6.2, POIt
<br />UN3291, Regulated Medical Wada, n os.,
<br />®
<br />6.2, PGII
<br />UN3291, Regulated Me"dcal Waste, n.o.s ,
<br />I �
<br />6.2, PGII
<br />UN3291, Regulated Maacal Waste, na s.,
<br />6.2, 121311
<br />tJl
<br />UN3291, Regulated geed Waste, nos.
<br />6 2, PGII
<br />UN3291, Regulated Medical ;9W,7&s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, rLo s.,
<br />6.2, PGII
<br />UN82g1, Raulated Medd Wade, nss.,
<br />852-001 GENERM MS REGISTRMWN #
<br />26, CONTAINER TYPE
<br />TBOS - 40 Gal Tub (Bio) (5.3 cu tt)
<br />TB49 - 37, "1 Tub (Bi*) (4.9 Cu tt)
<br />TB14 — 44 Gal Tub(Bi*) (5.9 cu tt)
<br />TB21-(Blo)/TP15-(Path)/TY].5-(Chemo)20 Gal Tub(2.
<br />YB31-(Bio)/wp31-(Path)/=31-(Chea®)31 Gal Tub (4.
<br />3-(Bic)/Fw43-(Path)/CK43-(Chemo) Gal Tub(S.7t
<br />KRB - Bioavatems Cardboard Box (4.2 cu tt)
<br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />described above by the proper shipping name, and are dassiffed, packaged, marked and labeiled/plecarded, a d
<br />are In all respects In e proper wndilton for transport according to appirc able international and n al gomme I regulabon� s.'
<br />_ � =Slanatuv"aNam(rli '� �Y
<br />4. TRANSPORTER 1 ADDRESS:
<br />Stericycle, Inc. 0 thisis trough Shipment
<br />a 4138 N. Swift Ave
<br />_ 0. Feeeno,CA 93722
<br />R.
<br />TRANSPORT QRCJERTI ICA 1p f icor waste as de bed
<br />Pdnt/lype No S�natu
<br />S. INTERMEDIATE HANDIER t / TRANSPORTER 2 ESS:
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pr1nUType Name Slanature
<br />C. NO. OF 20. VOLUME
<br />CONTAINERS
<br />Cu Ft
<br />Cu Ft.
<br />Cu FL
<br />Cu Ft
<br />Cu Ft
<br />Cu Ft.
<br />Cu Ft.
<br />(8647P-7422
<br />-7422
<br />It to Permit Nu ers.
<br />hauler Reg# 3400
<br />Phohe #
<br />Applicable Permit Numbers:
<br />Date
<br />ae 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #
<br />HNApplicable Permit Numbers-
<br />fR INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />— Prtnt/Type Name Stgnahcre Date
<br />T. DISCREPANCY INDICATION
<br />Trmforred M, ai R to : North 8d LaW, UT
<br />Preeno, t' CLAVE I
<br />(808'7( CMANNE ORTIZ ±
<br />MA FAILIA UsQ thaLl have
<br />id bove indicated wastes in acro
<br />n'
<br />MR %D°LkRr
<br />M -4 -MIN _,
<br />Stell ycte, Inc.
<br />1551 Sholon DI(Yit
<br />HoNster. CA 95023
<br />(8t "1131.7422
<br />eu. nnemace Facluw-
<br />Stericycle, Inc.
<br />8140 N 71h Street*
<br />Kerins City, K8 66115
<br />(M)783-7422
<br />TSADST-26
<br />authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />r with the requirement outlined in that authorization.
<br />Date
<br />
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