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<br />Protecting People. &edudng Risk:
<br />1. Generator's Name, Address and Tdle
<br />ATTN; Lori, Ey
<br />PACIFIC MEDICAL
<br />1700 K CRPJSMAN RD
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<br />SERVICE RECEIPT
<br />pC .1: 6019288-003
<br />Pacific MSI ical
<br />SERVICE DATE: 12128110 11:11:3.5 AM
<br />DRIVER 10: RJF
<br />SHIPPING D T t: R0&V0
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<br />CUSTOMER NUMBER - ti •"•
<br />2A. DESCRIPTION OF WASTE
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<br />UN3291, Regulated Medical Waste, n:o.s.,
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<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,`
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<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />SWdCyde Inc AtiltodeVe
<br />6.2, PGII
<br />7014 — 4
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />T67 L
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />6.2, PGII
<br />TB15 — 2i
<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />3. Generator's Certification: 1 hereby declare that the t
<br />described above by the proper shipping name, and are c
<br />are in all respects in proper cond• ion for transport accbri.
<br />PrintedrrypE -Name
<br />4. TRANSPORTER 1 ADDRESS:
<br />TOTAL. COLLECTED: 5,900 CU ET
<br />TOTAL VOI.t1NE:
<br />)OAOOW TB14
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<br />SUMK4M(Cont Type) OTY CF
<br />T014 44 Gal Tub(Bio), CT 12.7 1 5.900
<br />DELIVERY DOCUMENT 4: pDFR00AC40
<br />TOTAL DELIVERED ITEMS: 1 -
<br />QTY
<br />TYPE
<br />T814 44 Gal Tub(Blo), CT 12.7 Ib 1
<br />DRIVER: Fra s, Rarely James
<br />FREQUENCY: Cly -1
<br />KM plMp:
<br />CUSIGO SERVICE:
<br />Thank you for choosing Stericycle
<br />,''.ter:.Cyc ie, Inc,
<br />4135 West Swift Ave.
<br />Fresno, Ca 53722
<br />TRANSPORTER �fjTIFICATI&4 Receipt of medical waste as described
<br />Name
<br />STANDARD MANIFEST 001.10 -06 -STD
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<br />SEE LC OR MARCO ONI
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<br />ental regulations."
<br />tA)A Date
<br />Phone #: (559) 275 _ 0
<br />Applicable Permit Numbers:
<br />This In a. Through Shipment.
<br />5. INTERMEDIATE HANDLER 27 TRANSPORTER 2 ADDRESS:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrintfType Name Signature
<br />m 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
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<br />Z INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />z PrinUType Name Signature
<br />7. DISCREPANCY INDICATION
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />2C. NO. OF
<br />CONTAINERS
<br />2D. VOLUME
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<br />tA)A Date
<br />Phone #: (559) 275 _ 0
<br />Applicable Permit Numbers:
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<br />5. INTERMEDIATE HANDLER 27 TRANSPORTER 2 ADDRESS:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />m 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
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<br />Z INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />7. DISCREPANCY INDICATION
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />LEAVE AT.GFAF-MTOR
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<br />8A. Designated Facility:
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<br />2775 E 26TH STREET
<br />FRESNO,CA 712
<br />N SALT LAM OW, UT
<br />SIM Leirift. CA U577
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<br />C-REATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />:eived the above indicated wastes in accordance with the requirement outlined In that authorization.
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<br />Printf Type Name
<br />Signature
<br />Date
<br />LEAVE AT.GFAF-MTOR
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