|
01/24/2019 14:23 FAX Q0010/0010
<br /> '--'- MEDICAL WASTE TRACKING F&M Nt1MBEp
<br /> 4i s STANDARD MANIFEST 001-10.06-STD
<br /> -8.p Ste riC l: 1 SE OF EMERGENCY CONTACT:CHENtTREC 9.800-424.93
<br /> ° / Route #: 122 — 4 CUSTOMER NO,21132 MDFR00 LAV4
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ATTN:Ravneel Our 111 11 111 I1 1 i X111 N
<br /> DELTA SIERRA DIALYSIS CENTER
<br /> 555 W BENJAMIN HOLT OR STE 200
<br /> STOCKTON, CA 9520T-3838
<br /> (209)473-2294 11/26/2018
<br /> Cusromart NuauaR 6017746-002 GENERATow;REotarRAnoN r
<br /> 2A.DESCRIPTION OF WASTIE 2e, CONTAINER TYPE 2C. NO.OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste,n.o.s., CONTAINERS
<br /> 6.2,PGII TIM-28 Gal Tub(Bio)(3.7 cu III) Cu Fl.
<br /> UN3291Regulated Medical Waste,n.o.s., TB49_37 Gal Tub(Bio)(4.9 )
<br /> 8.2,PGII Cu Ft,
<br /> ®
<br /> UN3291 Regulated Medical Waste,n.o.s., 1 44 Gal Tub Blo (5.9 )
<br /> 8,2,PGII Cu FL
<br /> 8Uz32291,Regulated Medical Waste,PGII ,n,0.s., TB21-( )RP15-(_ _yTY1 )20 Gal Tub(2.7CUFT) Cu Ft.
<br /> III UN3291 Regulated Medical Waste,n,o.s.,
<br /> W ,62,PGII u FL
<br /> 6.2 Poll Regulated Medical Waste,n.o,s,, WB434_,)1WP43-(,____. ) 34- _._„)Gal Tub(5.7CUFT)
<br /> Qu Ft.
<br /> 6 2,PGII Regulated Medical Waste,n.o.s., KR _Biosystems Cardboard ox(4.3 cu rf)
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste,n,o,s,,
<br /> 9,2,Psi) Cu Ft.
<br /> UN3291 Regulated Medical Waste,n.o,s.,
<br /> 6.2,PGII
<br /> 3.CHms,rator's ConMcation:'I hereby deolare that the contents of this consignment are fully and accurately TOTALS ® ` Cu Ft.
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placa 4=;6
<br /> and
<br /> Varespects,in proper ndition for trans rt soon g to applicable International and no Name
<br /> ,,%,!qTRA SPORTER 1 ADDRESS: Phone#:(8010)783-7422
<br /> Stericycle Inc. This is a Through Shipment Applicable Permit Numbers:
<br /> 4135 W.iWilt Ave Hauler Reg#3400
<br /> Fresno,CA 93722
<br /> TRANSPORTERjCAffI5IMNecel Ical waste as de
<br /> Print/Typs Name Signetu Date
<br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone C
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDIER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/iype Name Signature Date
<br /> e e.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> Applicable Permlt Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/rype Name Signature Data
<br /> 7.DISCREPANCY INDICATION
<br /> e8.Atab Facllll :A.Dalgd Facility: 11C.Altamsta Factilty: SD.Ahamato Facility:
<br /> Inc. (Autodm)Au Steri Inc.(incinerator)I Saari , Inc.(Auto )A Covanta Marion, Inc Incinerate
<br /> 4135 .S"ft AMC 90 N.Foxboro Drive 1551 Shelton Drive 4850 Brooktake Road NE
<br /> Fresno. North Salt Lake,UT 840 Holster,CA 95023 Brooks OR 97305
<br /> (888)7 (801)938-1171 (888)783-7422 15051136-0890
<br /> wa TS/OST-22 8/JA-38 TS/OST•83 permit 0 364
<br /> � py 26 2018
<br /> TREAT ENT FACILITY:1 certify that I.have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the ted wastes in accordance with the requirement outlined In that authorization.
<br /> Print/Type Name Signature Date
<br /> Transferred containers, cu A to :Brooks, OR
<br /> Transferred containers, cu rt to :N.Sall Lake,UT
<br /> ORIGINAL
<br />
|