|
01/24/2019 14:22 FAX 90007/0010
<br /> O®
<br /> STANDARD MANIFEST 001-10-06-STD®/I °' E �� f1po424-83
<br /> Lf IC�/C e )�� � �
<br /> NO,21i
<br /> TEAR HERE --•--- a
<br /> 1.Generators Name Address and Telephone Nurntier SERVICE RECEIPT
<br /> ,�L�'-ft�:�dlwvneet Katir
<br /> D T IE_R DW.YSIS CEWER ACCOUNT 0: 6017746-002
<br /> 55 131f11J° 11d 1'41"i"Dtki t'i; QgP Datta sierra Dtaty�s's renter
<br /> SERVICE DATE: 12/6/ 1239 AN
<br /> gT0(FK rr0N, CA DRIVER ID: Flores, Sal =a
<br /> SHIPPING DOCUMEIJT M: MOFROOtCF!
<br /> CUSTOMER NUMBER (5017746-002 TOTAL COt LEC7EO: 8
<br /> 2A.DESCRIPTION OF WASTE 2B. TOTAL VOLUME: 44.000 CU FT 2C. NO.OF 2D. VOLUME
<br /> CONTAINERS
<br /> UN3291,Regulated Medical Waste,n.os., 1'}°IFO4 _ 8 C 1 Tub 1: o0A07t8t KA8F DOA07HII KRBF 0OA07H1 T014 Cu Ft.
<br /> G.2,PGII
<br /> UN3291,Regulated Medical Waste,n.o.s., -•3-1 Gall Rd OOAOIH2 T014 OOA07H3 7814 00AO7H4 T814
<br /> 6.2,PGII OOA07H5 T814 0OA07HO T014 Cu Fl.
<br /> UN3291,Regulated Medical Waste,n.o.s., , A--44 Gal'rof
<br /> j
<br /> 6.2,PGII Cu Ft,
<br /> 9
<br /> UN3291,Regulated Medical Waste,nVOL
<br /> .o.s., w..,. SUNMARY(Cont Type)
<br /> 6.2,PGII QTY CF Cu Ft,
<br /> I UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII KRBF Corr. Box Disp v/2-8gal 2 8.600 Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.c.s., -YY„^ T614 44 Gal Tub O1sD(Bto) 12, 6 35.400
<br /> 6.2,PGII _. Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., 1t DEIIVEAY DOCUMENT 8; PDfR00lCFL f
<br /> G,2,PGII Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., TOTAL DELIVERED ITEMS: 7
<br /> G.2,PGI) Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., TYPE 6.2,PGII QTY f Cu Ft.
<br /> 3,Generator's Certification:"I hereby declare that the contents,d. KRBF Corr. Box Dfsp u/2-filial Funnel TOTALS ® �( % /, '' Cu Ft.
<br /> described above by the proper shipping name,and are classified,j T844 44 Gat Tub Disp(aio) 12.7 lbs 1
<br /> are•1n all Ppspects in proper condition for transport according to apj 6 �ulations."
<br /> Printed/Typed Name.
<br /> 4.TRANSPORTER t``{GYtii Inc, 49aIB� Phone N;
<br /> IW-• 4835 W. �t-N ft Aw, DRIVER: Flores, Sal ' ApplicabloPorm;tNumbers:
<br /> lit
<br /> tjj(qr 11 eqj#34-04
<br /> p Ir't'r'",'s4'ta,CA 93722 FREQUEIICY: Veekly
<br /> co NEXT PICKUP; 12/10/18
<br /> Z TRANSPORTEE�,.CERTIFICA.T.9N Receipt;pf.medical was CUSTOMER SERVICE:
<br /> Fa- /I
<br /> Thank you for choosing Stericycle
<br /> Print/Type Nam
<br /> /;. r f S Date
<br /> 5.INTERMEDIATE HAIN LEA 2/TRANSPORTER 2 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> Lu
<br /> J
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFl(,A1 tuly. r,e—ip, ad above.
<br /> PrinUType Name Signature Date _
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone It:
<br /> w Applicable Permit Numbers:
<br /> IJ
<br /> a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> I=
<br /> Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> _,�Designated Facility: 88.Alternate Facility: ®8C.Aflernate Facility: E] 8D,Alternate Facility:
<br /> A tefl�y(._to.Inc.tAtut0rl1WVE-1 .i'rsrl��yclrs.is7n tltyC;tftOtfBttUl'� �cy�1 ,Itis.tAtt#�DGhbvci} C;::;reanla h:frili-frl,Inc;
<br /> '.�s 36 1/,r,Swift Avg 90 N,Foxboro t'.�ttal� 14�Ct Yl:«l�rt�t� �c,�iJ(9rr,I�kl�I•:r�iK;:���li�;
<br /> Fresno,0A 9;3,12 I•doft Sulk Lai(cy,UT 840644 HoIllater,CA U42$ 4:asr,u,<:s,t:7f`c 9730f,
<br /> 11.71 0; 670-7422
<br /> Y 'i''."�/f!S'f`•-;'.'� '3A'+:-4.)81 .A.34' TRIOST-83 r,nft-ld =,8W
<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 /> received the above indicated wastes in accordance with the requirement outlined in that authorization,
<br /> i8
<br /> Print type Name Signature "" Date
<br /> tv
<br /> OU ft to :N.Sib take, UT6
<br />
|