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<br />IN CAff,8�E1MW9PEyInCONTA JTpS' CHEMTREC 1.8DO-424.9300 oimiumnu mmmrcoi uuruo-ci--v m
<br />CUSTOMER NO. 21132 MDFROOP 5114
<br />Munin"rsru - WiliffrR1011. IV x lit? . 13fuu fS, vr%
<br />Transferred contalnem, _ cu t to : N. Satt Lake, UT
<br />nAlrantee
<br />1. Generator's Name, Address and Telephone Number
<br />Ar d
<br />I
<br />I + 1 11 I !I
<br />SGW STOCKTON MEDICAL PLAZA 1
<br />2 505 W HAlvtivE R LN
<br />STOCK70N, CA 95208- 2$39
<br />(209) 422-7578
<br />8/10/2021
<br />CUSTOMER NUMBER 6131468-00 1 GENEHATOR•s REGISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />20, CONTAINERTYPE
<br />20. NO. OF
<br />2D, VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TB04 - 28 Gal Tub (Bio) (3.7 cu 11)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu I
<br />UNRegulated
<br />Regulated Medical Waste, n.o.s„
<br />TB49 - 37 Gal Tub (Bic) (4.9 CV t)
<br />6
<br />Cu
<br />M
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />T814 -44 Gal Tub(Blo) (5.9 cu fl)
<br />p
<br />6.2, PGII
<br />Cu I
<br />UN3291 Reg ulaled Medical Waite, n.o.s„
<br />T021-(^,^ , ! U
<br />6,2, PGII
<br />Cu I
<br />W
<br />UN3291 Requlaled Medical waste, n.o.s„
<br />6.2, PGII
<br />Cu
<br />tZ
<br />UN3291 Regulated
<br />ftequlaled Medical Waite, n.o.s.,
<br />y4343�{�1,M/�C43{_} Gal Tub(5.7CU
<br />6
<br />Cul
<br />Medical Waste, n,o.s.,
<br />KR_Regulated
<br />KR,^-_, - Biosystems Cardboard Box (4.3 cu I1)
<br />62, PGI
<br />Cu I
<br />UN3291 Regulated Medical Waste, n o.s,,
<br />6.2, PGI/
<br />Cu I
<br />UN3291 Regulated Medical Watte, n.o.s.,
<br />6.2, PGII
<br />CU -1
<br />3. Generator's Certification:'1 hereby declare that the contents of this consignment are fully and accurately TOTALS III -,Cu
<br />I
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are In all respects In proper oonditlon for transport according t`o applicable International and national governmental regul tions"
<br />41
<br />Pdnle t`� ad Name �� C in `( Signature r%L" Date
<br />4. TRANSPORTER 1 ADD S;
<br />licy�Is, Inc. ❑ This is a Through Shi meet
<br />Phone 4: ^
<br />4135 W, SWII1A a
<br />Applicable Permit Numbers:
<br />N auler Reg# 3400
<br />�
<br />F ro: no,CA 93722
<br />TRANSPORTER ICATION: Receipt of medics waste as described above,
<br />17�alure
<br /><� /
<br />Print!Type Name
<br />S. INTERMEDIATE MINDLER 2 /TRANSPORTER 2 AbDA S:
<br />Dale —
<br />Phone 4;
<br />Applicable Permit Numbers:
<br />i
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Aecelpl of medical waste as described above.
<br />Print/Type Name _ Signature
<br />Data
<br />8, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone 4:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Applicable Permit Numbers:
<br />Print/Type Name Signature
<br />Dale
<br />7. DISCREPANCY INDICATION
<br />❑ 8A. Deelgneted Feclllty: 89, Alternate Facllfly: 8C. Altemate Facility:
<br />❑ 80. Allemale Facl(tty:
<br />I
<br />Steticycle, Inc. (Autocisve) StericycleInc, Incinerator) Stedcycle, Inc. (Autoclave)
<br />9"
<br />Covante Mallon, Inc
<br />I
<br />4176 W SWRAVa 90 N. FOX60ro 1661 Srhalton DrfvA
<br />4250 firaakfako RAad NG
<br />F!mwv, OA 0072# Naris, 0elkLake, UT W04164 Mvlllbllw), SOA 0#020
<br />DFvvhb, on 070of
<br />kl'�('IM�i'�Fi71Z toatyeoa-i��t (dlilij7dy-?'AYY
<br />i'S1t 'It vFp 3A-448/JA-36
<br />{SCJ6)Jsl�-C2l�Jp
<br />i
<br />TS/OST-83
<br />Pern it# 364
<br />AIN 14 2021
<br />TREATMENT FACILITY; I certify that I have been auAorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received theAboVeJAklated wastes in accordance with the requirement outlined In that authorization,
<br />PrinVType Name Signature
<br />Dale
<br />Munin"rsru - WiliffrR1011. IV x lit? . 13fuu fS, vr%
<br />Transferred contalnem, _ cu t to : N. Satt Lake, UT
<br />nAlrantee
<br />
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