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01/24/2019 14:22 FAX R0008/0010
<br /> o®e btenCyc 1 E OF EMERGENCY 601XKVICE RECE STANDARD MANIFEST001.10.06•SlU
<br /> 1 R.+ # : 12,2 ACCOUNT C 6017746-002
<br /> 1.Generator's Name,Address and Telephone Number Delta Sierra Dialysis Center
<br /> SERVIC
<br /> ATDRIVEREID: Flores, Sa15:00:52 AN
<br /> �t"f�:f�t�yne-el E%iljd P6
<br /> Ddid."dA b.sdERRA D[AL 1''M CENTER j
<br /> 556 W 8d=dsb,:d,P4/siN HOd.d DR .c'a d`E 200 i SHIPPING DOCUMENT#. MD S
<br /> S TOCKTt N, (A 66207-- 3839 � Torat collEcreO: s
<br /> TOTAL VOIUME: 29,500 CU FT
<br /> CUSTOMER NUMBER 6(0)11 17 6-1) � � 0OA07147 T814 0OA07N8 T014 OOAO7H9 T814 _
<br /> 2A.DESCRIPTION OF WASTE 2H. CONJ OOA07HB T814 OOA07HC T014 2C. NO.OF 20, VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., CONTAINERS
<br /> 6.2,PGII 'PB0 - '?E',G all Tub 0a '3.7 0, VOI Cu I
<br /> 6
<br /> UN3291,
<br /> Regulated Medical Waste n.o.s., SUMMARY
<br /> 37 did �� (k3dt�.1 �Q SUMMARY(Cont Type) QTY CF Cu
<br /> CC UN3291,Regulated Medica(Waste,n.o.s., r.� � T � � �•,��% dt4� ; T814 44 Gal Tub 0isp(8io) 12, 5 29.500
<br /> O ) CU
<br /> `� G 23PG111 Regulated Medical Waste,n.os., �• � t`„}V `1/1 I G-c.........„„)!1- , DEIIVEAY DOCUMENT #: POFROolBUS
<br /> (r Cul
<br /> W UN3291,Regulated Medical Waste,n.o.s.,
<br /> iZ 6.2,PGII TOTAL DELIVERED ITEMS: 6 Cu I
<br /> UN3291,Regulated Medical Waste,n.o.s., j
<br /> 6.2,PGII W04.34, )MIJ434 TYPE QTY Cu I
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII KR -Biosystems ar d caCu I
<br /> T814 44 Gal Tub Disp(81o) 12.7 lbs 6
<br /> UN3291,Regulated Medical Waste,n.os.,
<br /> 6.2,PGII
<br /> Cul
<br /> UN3291,Regulated Medical Waste,1)— s., _
<br /> 6.2,PGII
<br /> Cul
<br /> 3.Generator's Certification:"I herebydeclare that the contents of this cons( nr. �. `' \
<br /> dosc ''bed above by the proper shippinname,and are classified,packaged,ma DRIVER: Flores,: Week $al 1 7 Cu I
<br /> are in}all respects in proper condition for transport according to applicable intern; FREQUENCY: Weekly
<br /> t NEXT PICKUP: 12/6/18
<br /> lCUSTOMER SERVICE: r
<br /> rintodRyped Name � Dalq'______
<br /> 4:TRANSPORTER 1 ADDRESS: Thank you for choosing Slericycle Phone ll; ;o..
<br /> _ ILU
<br /> - Star4C�/�.:de, inc. Applicabl Pe�fi Numbers:
<br /> L._l
<br /> a 4.136 W, �Wft Ave
<br /> i o Mauler RoUft. 400
<br /> N Freasnu,CA 933722
<br /> Q TRANSPORTER CERTIFICATION: Receipt of medical waste as describe( /
<br /> Printrrype Narne_ 1/__ ! j Signature Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone if:
<br /> ¢� Applicable Permit Numbers:
<br /> ow
<br /> wo
<br /> x INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone if:
<br /> Qw Applicable Permit Numbers:
<br /> W-'
<br /> W e INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> LS
<br /> z Printrfype Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> K 8A.Designated Facility; 88.Alternate Facility: 8C.Alternate Facility: 8D.Alternate Facility:
<br /> �.n ❑ ❑ Y� ❑ Y:
<br /> 0,�' rd dt , frit. dlacldr��r�tt�lt) ititt: t Ine. *060 0A C(xvanta vNiarian. 9t,t, ltieiste�t 4
<br /> c�IC4rtt�Fi�1 lrtt. (atl'1.tlindzd�C4d At9 + 't ”,
<br /> 41 V �.:a"il Aar* 00 N. Foxfa�len , rise .1-:40b"90 Drive 01A f3rooklake Road
<br /> ° r K-ut4iiti 54A.443,nm Wwth .1_o$tes,kXV "66 1 .qlT . 1i' r 1`.2Yt:+tt4(Sl, °4 'iT°oik4J
<br /> (506 183-79.4: #801)U36-1171 40w, 7 �JG"i3ssi,!-Uliq
<br /> �6 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 /> 5
<br /> Print(Type Name Signature Date
<br /> Transfierret _...__._.- t.e da llnenZ ou 4 to :Br4y>>ks,I
<br /> Transferred Cerrtii�it���a�a:� ,�.„. . �, �.ou R to .,N,Salt tido,L f
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