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®®®® Steric Cie• <br />°•® r+. 1" <br />IN CASE OF EMERGENCY CONTACT CHEMTREC 9.800-124-0300 <br />CUSTOMER NO. 21132 <br />L91 V tti 10 F.1 10 1 c7_[y / I `IN •I•TA 11 dtl Yiai <br />1. GeneratoNs Name, Address and Tel OUN thlx ilr'� 1� <br />tnUt±'KUUrt �N3 <br />ATTN o <br />111111111111111111111 M111 <br />G1ZL MEDICAL CENTER <br />1617 N CALIFORNIA ST <br />STOm=Nj CA 95204- 6117 <br />CUSTOMER NUMSQR GSENERATows RE umuTt oN # <br />117372015 <br />2A. DESCRIPTION OF WAS% <br />CONTAINER TYPE <br />2C. NO. OF <br />20. VOLUME <br />CONTAINERS <br />UN3291, Regulated Medical Wade, no.s., <br />CU Ft. <br />6.2, Pall <br />UN3291, Regulated Medical Wade, n o s., <br />T805 - 40 GalT t39.O (5.3 cu <br />6.2, Pall <br />Cu FL <br />UN3291, Regulated Me" Waste, n o a, <br />Cu Ft <br />UN3291, Regulsted Medkal Waste, no s , <br />Cu FL <br />6.2, Paan(HM <br />- <br />UN3291, Regulated Medical Wade, n o.s., <br />W <br />6.2, Pill <br />Cu FL <br />UN3291, Regulated Madleal Waste, nam, <br />6,2, pan <br />CU FI <br />UN3291, Regulated Meftd Wile, n o a., <br />6.2, Pail <br />CU FL <br />UN3291, Regulated Medled Wast% nA.L. <br />isjoRyistems 1;Zraboarcl, Hoic-(4.2 <br />6 2, Pall <br />CU FL <br />UN3291. Regulated Meftl Waste, nam, <br />62, Pall <br />CU R <br />3. Generator'B Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS <br />` <br />Cu Ft <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />0 respects In proper cortditiott for artsport accordrng to applkxrbta international and r+ahona! mme regulabons.' <br />QrntedlTyped Name Signa <br />D to <br />a <br />. PORTER 1 ADDRESS: <br />Phare # <br />171 ;feta 422 <br />Stericycle, Inc. This is a Through ShipmentAppQcabl <br />4 <br />4735 W. SwiftAveHauler <br />Reg# 3400 <br />aTRANSPORT <br />- eRl I R&Ipt of medical waste as desen s <br />5ifSignature <br />Printrrype Name <br />Date - - <br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Phone tk <br />SApplicable <br />Permit Numbers: <br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as descnbed above. <br />Print/Type Nance Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 / TRANSPOiRR,3 ADDRESS: <br />Phone A <br />5 <br />Applicable Pemtd Numbers: <br />2 <br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />- <br />PdnV ype Nama Signature <br />Date <br />7. DISCREPANCY INDICATION <br />d4i fn <br />Ignalod F881111y <br />M Altemate <br />.J <br />Fsonli : 88. Atterrr`- aOB75 Nltyr . Alternate <br />Facility: <br />WQ f 9 <br />Steri le, Inc. A TOC L V� ®Inc. Stericycle, Inc. <br />SUricycle, Inc. <br />4136 ' Swinti� LE ANNE R-�� N. F or* Diwe 1651 Shelton Drive <br />3140 N 7th Streettrfy <br />Fresn ,CA 937 'tvotth Salt ke. UT 84050 Holllster. CA 85023 <br />(886)7 3.7422 422 <br />Kansas Clty, KS MI IS <br />(866)IM (866)78&7421 <br />(866)783-7422 <br />TWO `"' N®V 0 3 2015M44" 36 TSIOST 83 <br />TSIOST 26 <br />TREATME FA�IOTY: I certify that I have been au orized by the applicable state agency to accept untreated medical wastes and that I have <br />the <br />received boVe ind A I" mance with the requirement outlined in that authorization. <br />PrinNType Nam Signature <br />Date <br />co <br />co <br />Q <br />C.7 <br />L91 V tti 10 F.1 10 1 c7_[y / I `IN •I•TA 11 dtl Yiai <br />