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01/24/2019 14:23 FAX IN009/0010
<br /> i s �teric• m >cnviu �«�••• STANDARD MANIFEST 001.10.06•STD
<br /> ,p Sycle I E OF EMERq
<br /> ACCOUNT li: 6017746.002
<br /> 1.Generator's Name,Address and Telephone Number'; Delta sierra Dialysis Centerf
<br /> SERVICE DATE: 4:52:59 AN
<br /> nTIN' Wa�Ieel101.1fDRIVER ID: Flores, 531
<br /> DELTA SIERRA DIALYSIS CENTER
<br /> 15'Nyr5'11�t1ft t�
<br /> LJEN,JAIAN �{(pjLT ��y'j8�7rS I'�' r2.00 SHIPPIII6 DOCVHEIIT III: HOFROOIBHO
<br /> ST( YON, CA
<br /> TOTAL COLLECTED: 9 11129/201,^,
<br /> TOTAL VOLUME: 45.000 CU FT
<br /> CUSTOMER NUMBER "' 6„ i:' ! oOA076P KR8F 00AD76S KR8F RXA07CO RX90
<br /> 2A.DESCRIPTION OF WASTE 28• i 00A0760 TB14 0OA0760. 7814 ODA07GT TB14 2C. NO.OF 2D. VOLUME
<br /> i 0007W 7814 0OA076X TB L4 OOA07HA T014 CONTAINERS
<br /> G.23PGI1 Regulated Medical Waste,n.o.s., �. a T i l9ll y)t11D ll4Y VOL Cu F
<br /> UN3291,Regulated Medical Waste,n.o.s., y
<br /> 6.2,PGII �����" ��I �� g�l�i+ SUHHARY(Conl Type) QTY CF Cu f
<br /> CC UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII 0 ( {� -�44 Gael`C�uN81a)
<br /> KRSF Corr. Bol Disp v/2-8gal 2 8.600 i.-' r I Cu f
<br /> Q UN3291,Regulated Medical Waste,n.o.s., T021 W ��' RX90 9 Gal llhiLe•Blue Rx Shar 1 1.ODD
<br /> ICC 6.2,PGII t,_••wy/` '° ---� Cu f
<br /> W UN3291,Regulated Medical Waste,n.o.s,,
<br /> f T814 44 Gal Tub Disp(Bi o) 12• 6 35.400
<br /> Z6.2,PGII ",, t�.� f, cr:. ..
<br /> W UN3291 Regulated Medical Waste,n.o.s., DELIVERY DOCUMENT d: PDFROOLBHO Cu 1
<br /> 6.2,PGII �� ;) UP4.3 ? Cu I
<br /> UN3291,Regulated Medical Waste,I1.O.S., o TOTAL DELIVERED ITEMS: 7
<br /> 6.2,PGII KR __t3itY, t�rrEai GsIC Cu I
<br /> UN3291,Regulated Medical Waste,n.o.s., TYPE QTY
<br /> 6.2,PGII Cu I
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII KRSF Carr 80, Disp v!2.8ga1 Funnel 1 Cu I
<br /> 7814 44 Gal Tub DisptBio) 12.7 lbs 6 LS ,
<br /> 3.Generator's Certification:"I hereby declare that the contents of this co t. Cu I
<br /> described above by the proper shipping name,and are classified,package
<br /> prerilvallyespects in proper condition for transport according to applicable)
<br /> i...
<br /> Pri(i{ed/Typed Name r .i. DRIVER: Flores, Sal PhonoN(8
<br /> � Dale
<br /> qP
<br /> 41Tf)pNSPORTER 1 ADDRESS:
<br /> 1fy )
<br /> W ��rl_ .,_ II�L FREQUENCY: Neekly `'�ApplicablePermit Numbers:
<br /> 4135 WN fl tIEXT PICKUP: 1213,18
<br /> CC O CUSTOMER SERVICE: klit.Gl4tReg'�`) 0
<br /> a. Fresno,CA 03722 Thank you for choosing Stericycle
<br /> i Q TRANSPORTEI3..C.F;RTIFICATION: Receipt of medical waste as desc
<br /> l / r
<br /> } ! r> Si nature Date f
<br /> PrinVTypo Name 9
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> 5� Applicable Permit Numbers:
<br /> ;pw
<br /> W—�
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrinVType Name Signature Dale
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone It:
<br /> u a Applicable Permit Numbers:
<br /> -ow
<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 /> Facility: 8B.Alternate Faculty: 8C,Alternate Facility: 8D,Alternate Facility:
<br /> -' b f?.QA,..D.eslgnated
<br /> wr3cr�ria,. ilei;.. ( +altaz:l �+es},, � ;terftw� i .In Incinerator) Inc Sterle Inc. (Autadk v��*i rpt C,avanta�v1;W�i�st�. I�id; fF�ritFr:�a1
<br /> 9 413 3`,r . Frtnfi9l Ave 0 N. Foxhcorc , rlve IN li.ckan�dve 4850 €roatt��Wkeb €�;rs,+a,i
<br /> L 11"ta1x lo, C;A!�'S'122 McfA o Suk Lake.Ur 84464 Holl sterNQXa BY04kt OR £L INN
<br /> (860)783-7422 (801)930-11'71 (81BOVOi x'422
<br /> .5 TS/04.3722 3A4481,14-aO TSIOV-811 Permit#S64
<br /> a
<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 /> L received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Print(Type Name I Signature Date
<br /> ContainOru, 4 to :Brooks,OR
<br /> 'I Etin.i rat( — _ c:rorlla�nt�ru, ou R io : N.Sol take,€ T
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