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01/24/2019 14:22 FAX Q0006/0010
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<br /> WASTE TRACKING FORM NUMBER
<br /> ®•®e ElAf-1 SESTANDARD MANIFEST 001-10-O6-STDJteicyclem
<br /> MIA, ilk)l.lcS j
<br /> 1. Generator's Name,Address and Telephone Number ' ACCOUNT A: 6017746.002 }(f
<br /> Delta Sierra
<br /> Dialysis Center
<br /> 11���.Rayneet �:nur SERVICE DATE: 12/10/18435: 24 AM
<br /> DELTA SIERRA CAALYSIS GEI+ITE.R DRIVER ID: Flores, sat
<br /> 555 W t3EI+IwWAIN HOLT DR SSE 200 i
<br /> as TOCK`€'s;N, CA 96207-;9830 1SHIPPIMG DOCUMEtl1 OOtCSZ
<br /> TOTAL COLtECTEO: 6
<br /> 0OA07HE T014 0OA07HF 7814 0OA078H T814 2C. NO.OF 21).TOTAL VOLUME: 35.400 CU FT
<br /> CUSTOMER NUMBER
<br /> 6011146-002 VOLUME
<br /> I
<br /> 2A.DESCRIPTION OF WASTE 2B. OOA07HI TEN OOAO7H3 T814 OOA07MK T814 CONTAINERS
<br /> UN3291,Regulated Medical Waste,n.o.s., 7804 - 28 Gal Tub (81ol,"
<br /> 6.2,PGII Cu Ft.
<br /> 6.23291,Regulated Medical Waste,ll.o.s.,
<br /> UR•- 31 Gc'BI'Iub (lV 6 SUNNARY(Cont Type) VCF
<br /> Cu FL
<br /> 6.2,PGII ___ YP ) QTY CF
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 44, Gal )"t111(IIp�;
<br /> 6.2,PGII T814 44 Cal Tub Oisp(8io) 12. 6 35.400 —� l Cu Fl.
<br /> UN3291,Regulated Medical Waste,n.o.s„ 141.1-11—)[l -(_,»fl i Cu Ft.
<br /> 6.2,PGII DELIVERY DOCUMENT#: POFROOLCS2
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII Cu Fl.
<br /> 6.23291,Regulated Medical Waste,n.o.s..
<br /> DELIVERED ITEMS: 9
<br /> WV843., -
<br /> 6.2,PGI) �----)/U P4-3�»+ Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., TYPE
<br /> 6.2,PGII KR w I3io ttetyils 0 QTY
<br /> CU Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s„ KRSF Corr. Bot Ofsp u/2-8931 Funnel 3
<br /> 6.2,PGII T814 44 Cal Tub Ofsp(Bio) 12,7 lbs 6 Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII Cu Ft.
<br /> 3.Generator's Certification:"I hereby declare that the contents of this ALS ® Cu Ft.
<br /> described'above by the proper shipping name,and are classified,pack
<br /> arp-in-ail respects In proper condition for transport according to applica; DRIVER: Flores, Sal pns:'
<br /> i
<br /> % FREQUENCY: lieekly ' Date
<br /> Pri:iod/Typed Name NEXT PICKUP: 1211?/18 Phone N: '$ _3.e1 V �
<br /> 4,.TRA SPORTER 1 ADDRESS: CUSTOMER SERVICE:
<br /> Steric le Inc. Th ( Applicable Permit Numbers:
<br /> >J 4`135�� V�WO $ Thank you for choosing Stericytle �
<br /> a W. Vlaute r Re .3400
<br /> y Fraslno,CA 03122
<br /> » i
<br /> TRANSPORTER CERTIFICATION: Receipt of medical waste as
<br /> Print/Type Name Signa,,, Date
<br /> 5,INTERMEDIATE HANDL R 2/TRANSPORTER 2 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
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<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print(Type Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> ¢ Applicable Permit Numbers:
<br /> a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> x
<br /> Print(Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> z
<br /> A.Designated Facility: 8B.Alternate Facility: ®8C.Alternate Facility: 80.Alternate Facility:
<br /> rs mts>rl?-yrle:inc.(Auto lave) �Slertc\rcle,Inc.(Incinerator) S1�rlc cle,Inc,(r�iAoclaiv�a) 0.;vanta Marion,inc;
<br /> Q i s ! /0 N,f embtal`t5 DriiVttt ��2�w1 Ort?;',/;.I�U'Ikl% {':o CI NE
<br /> �1�.C 4V,�.thtll�7��/1: 1��1 ht�ICQPY�t��
<br /> P rew-t,,P;°A 93'7`22 Horth SsIt t..o4b,UT 84064 Mo Wer,CA 56024 OR V'305
<br /> j6513)733-742.? (601)936-1171 (666)753.7422 {PSr��t>3�13-C1�390
<br /> "rsio S'1"_22 3A-4481lA-3115 TSIOST M Permit#3F4
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<br /> TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> JR received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> J
<br /> Print(Type Name Signature !' Date
<br /> ou ft to ' Foey $, OR
<br /> ivritt.ainam ._ n ..cru ft to :N.Sok Lake, UT
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