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t- a Stencycie IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-4249300 0 Mrvunnv MANIrao, "].Va-c.-irvvn
<br />R01.1le 3P. 704-5 CUSTOMER NO, 21132 MDTIF0005013
<br />1. Generator's Name. Address and Telephone Number
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<br />ATTN'. Dwain
<br />jPLAZA �!i i���l�i����il�� l� 4 �� !I�
<br />l��i��i����ll11,1111
<br />RXWj GN E MEDICAL 1
<br />2505 W HAMMER LN
<br />11/24/2021
<br />STOCKTON, CA 95209-2839 (200) 521-6097
<br />CUSTOMER NUMBER 6131,168-750 GENERATOR'S REGISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />2B, CONTAINERTYPE
<br />2C, NO. OF
<br />2D, VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />, r
<br />1�RR2-(Pharrn)2 ShelfMeeled Rack(48 Cult.)
<br />CONTAINERS
<br />6.2, PGII
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<br />62,P9G11IRegulated Medical Wasle,n.o.s.,
<br />MRS-(Pharni) u Shelf Wheeled Rack (52 Cult,)
<br />'CU
<br />0
<br />O
<br />6.23 PGII 1Regulated Medical Waste, n.os.,
<br />RX-(PIlairil) r al, Con-uptedBox- (4 .32 CuQ.)
<br />Cu
<br />UN3291 Regulated Medical Waste, n.o.s,,
<br />6.2,PGIl
<br />n7
<br />RX_ (Ph@rrn)______Caal. Can-Ug•3ted BOX (4.32 CUit.)
<br />Cu
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s,,
<br />6.2, PGII
<br />.
<br />, Cu
<br />UN3291 Regulated Medical Waste, n,o.s„
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<br />6.2, PG I
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<br />6 23 PGII Regulated Medical Waste, n,o.s,
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
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<br />UN3291 Regulated Medical Waste, n.o.s,,
<br />6.2, PGIi
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<br />3, Generator's Certificatlow "I hereby declare that the contents of this consignment are fully and accurately TOTALS ►
<br />1'7,2 Cu
<br />described above by the proper shipping name, and are classllled, packaged, marked and labelled/placarded, and
<br />are In all respects In proper conn�dliion for transport according to applicable International and national governmental regul
<br />Print Name / y P, NC SI nature
<br />4.TRANSPORTER I ADDRESS:
<br />Dele - '
<br />Phone H; (20 9) 2 94-T-1 14
<br />Stericycle,111C. This is a ThrOtujh Shi)JI111ent
<br />Applicable Permit Numbers:
<br />a
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<br />J
<br />7375 R A f3ridg ford Rd.
<br />TS/OS-f-80
<br />0Stockton,
<br />CA 95206
<br />i Q
<br />TRANSPORTER, CERTIFICATION: Receipt of medical waste as described ve,
<br />4(4-
<br />1 1 ►y1/
<br />Fdn*pe Name V UGC `Q��A Signature
<br />5, INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />Phone N:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pdntllype Name Signature
<br />Dale
<br />1
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone q:
<br />Applicable Permit Numbers:
<br />UJ
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste es described above,
<br />S
<br />PrinVlype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />6A, Designated F4cllity; J 69, Aitarnate Facility: [] eC. Alternate Faclltty:
<br />SD. ANamala Facility:
<br />3 1n
<br />5tericyolN, lnc. (Autoclave) Stericycle, Inc. (Incdnerator) Cterioycle, Inc. (Autoclave)
<br />Ccvarf n I
<br />L
<br />7875 R A 8ridgebord Rd. 90 N. Foxboro Drive 2175 E. Zt3tit St,
<br />WA
<br />4 ' ���er� p
<br />Sto-;I(0n, CA J520P North Salt Lake, a IT 0,105x1 Vernon, GA +�005B
<br />Eireol�s, Ci . 5
<br />(209)299-7114 (801)938-1171 (886)788-7422
<br />(505 C°a(l
<br />S
<br />E S
<br />T5103 BO 3N 448/JA-3d
<br />Penr, 31 , 2021
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<br />TREATMENT FACILITY: f certify that I have been authorized by the applicabte state agency to accept untreated medfoal that i have
<br />received the above Indloated wastes In accordance with the requirement outilned In that authorization.
<br />t'
<br />itaapl
<br />PrinIMpe Name Signature
<br />Date
<br />nQrr-1lntet
<br />
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