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'®®®• StelrN C e- IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.000-4249300
<br />®•� FMICAVRoute #: 023 - 8 CUSTOMER NO. 21132
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />BILL MEDICAL CENTER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6111
<br />451-9031
<br />CUSTOMER NUMBER GENERATORS RE6157MMON #
<br />2A. DESCRIPTION OF WASTE 21L CONTAINER TYPE
<br />UN3291, Regulated Medics! Waslo, mor.,
<br />62, PGII TE05 — 40 Gal Tub (Bio) (S.3 est ft)
<br />UN3291, Replated Medical Waste, n o s.,
<br />6.2, PGII TB49 - 37 Gal Tub (Bio,) (4.9 Cu ft)
<br />0
<br />UN3291, Regulated Medial waste, n os ,
<br />O 8 2, PGIIT814 - 44 GSI Tub (Bio) (5.9 CU; tt)
<br />UN3201, RegAW Medical Warta, no u, TB21- (BIO) /TP15— (Path) /TY15- (Chemo) 20 Gal Tub (2.7CUPT
<br />8.2, PGI(
<br />W UN3291, Re9daW Medical waste, nos, WB31- (Bio) /WP31- (Path) /WC31- (Chemo) 31 Gal Tub (4.14CUF
<br />rZ 6 4 PGII
<br />1.11032111, Regulatel MedlW fteta, n.oAa,
<br />6.2,?Gil WB43— (Bio) /PTd43— (Path) /CW43— (Chemo) Gal Tub (5.7CUFT)
<br />UN3291, Regulated Medkal,waste, n o s.,
<br />6.21 PGII Ms — Biosystems Cardboard Box (4.2 cu ft)
<br />UN32911. Regulated Medical Waste, n.os„
<br />62, PGII
<br />UN3291, Regulated ti cal Wasle, nos„
<br />6.2, PGII
<br />3. Genera 's Certification: 11 hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />de ab a by the proper shipping name, and are ed, packaged, marked and labelledlpla Wndinag resp cts In proper condition for transport akx ordheg to appt bte iMematronet and patron ovar trcxts "
<br />..ti ,.........,
<br />Pri (Typed Name 9nature
<br />4. TRANSPORTER 1 ADDRESS:
<br />Stericycle, Inc. 0 Thin is a Through shipment
<br />4135 V. Swift Ave
<br />'N Freano,CA 93722
<br />a TRANSPORTER RTIFI ATIO . celpt of infAcal waste as des ' ed a ve '
<br />Print/1Voa Name Stonature
<br />:C. NO. OF
<br />CONTAINERS
<br />015
<br />LUME
<br />Phonet (866) 783-7422
<br />Applicable Permit Numbers:
<br />Hauler Reg# 3400
<br />Date
<br />Cu FL
<br />Cu Ft.
<br />Cu FL
<br />Cu FL
<br />Cu Ft.
<br />Cu A
<br />Cu FL
<br />Cu FL
<br />m�
<br />7. DISCREPANCY INDICATION
<br />Transferred containers,
<br />aA Designated Facility; Ba, Alternate Facility:
<br />ticycle, Inc cycle, Inc.
<br />CLAVE 90 *xbora®t'o
<br />r
<br />,122ANNE ORT Z N Salt Lake, UT 34054
<br />►�'�` OCT 13 201
<br />d.. A�CILITY. I certify that I hm
<br />- cu R to : North Sak Lake, UT
<br />aC. Alternate Facility: L
<br />Sbericycle, Inc.
<br />1551 Shelton DrbM
<br />Holllster, CA 9SD23
<br />(966)783-7422
<br />TWOST 83
<br />Steticycle. Inc.
<br />3140 N 7th Straettfly
<br />Kansas City, KS 6611 S
<br />(866)793.7422
<br />TSIOST 26
<br />authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />l with the requirement outlined In that authorization.
<br />eTL Tat1.G-hRG DOCUMENT
<br />Date
<br />S. INTERMEDIATE HANDLER 217RANSPORTER 2 ADDRESS: :'
<br />Phone 4:
<br />Hs
<br />Applicable Permit Numbers:
<br />,S
<br />INTERMEDIATE HANDLER 1 TRANSPORTER CERTIFICATION: Receiptof medical waste as deswmbed above.
<br />prinUiype Name Signature
<br />Date
<br />C INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: ,.
<br />Phone #:
<br />S
<br />Applicable Permd Numbers:
<br />�
<br />INTERMEDIATE HANDLER !TRANSPORTER CERTIFICATION: Receipt of Medical waste as described above.
<br />z
<br />Prinveype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Transferred containers,
<br />aA Designated Facility; Ba, Alternate Facility:
<br />ticycle, Inc cycle, Inc.
<br />CLAVE 90 *xbora®t'o
<br />r
<br />,122ANNE ORT Z N Salt Lake, UT 34054
<br />►�'�` OCT 13 201
<br />d.. A�CILITY. I certify that I hm
<br />- cu R to : North Sak Lake, UT
<br />aC. Alternate Facility: L
<br />Sbericycle, Inc.
<br />1551 Shelton DrbM
<br />Holllster, CA 9SD23
<br />(966)783-7422
<br />TWOST 83
<br />Steticycle. Inc.
<br />3140 N 7th Straettfly
<br />Kansas City, KS 6611 S
<br />(866)793.7422
<br />TSIOST 26
<br />authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />l with the requirement outlined In that authorization.
<br />eTL Tat1.G-hRG DOCUMENT
<br />Date
<br />
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