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y � �MEDICALWASTETRAGKiNG FORM NUMBER
<br /> F49*06S C,PaC�/GI@• 1 CAS QOF E �jCY CO ACT:CHEMTREC 1-800-424.9300 STANDARD MANIFEST 001-10-06-SM
<br /> rm,auo,,,p,.aeadnomOu"` "' "' — CUSTOMER NO.21132 MDFROOHBVG
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ATT1;I:Remi Tabangaura f 11 t
<br /> ` DELTA SIERRA ATALYSIS CENTER
<br /> 555 N BENJAMIN BOLT DR STE 200
<br /> STOCKTON, CA 95207— 3839
<br /> (209) 473-2294 114/2016
<br /> Cus,romERNumsER 6017746-002 GENERATORS REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 26, CONTAINERTYPE 2C.NO.OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste,n oz., TB05 – 40 Gal Tub (Bio) (5.3 cu ft) CONTAINERS
<br /> 6.21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste,n o s., TB49 – 3 al Tub (B a} (4.9 cu ft)
<br /> 6.4 PGII Cu Ft.
<br /> f� UN3291,Regulated Medical Waste,n.o.s., B14 – 44 1 T B a cu
<br /> 0 6.2,PGII Cu Ft.
<br /> Q8 2322G1`Regulated Medical Waste,n.o.s., – Cu Ft
<br /> W UN3291 Regulated Medial Waste,n.c.s., WB31–(B o) WR31–(Path)7f4C31–(Chemo)31 Gal Tu
<br /> W 6.2,PGII Cu R
<br /> 6N3291.
<br /> 3229111 Regulated Medial Waste,n.o s, NB43–(Bio)/PW43–(Path)/eta43–(chemo) Gal Tub(S.7CUPT)
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste,n.o.s., KRB – Biosystems Cardboard. Box (4.2 cu ft)
<br /> 6.2,PGII — Cu Ft.
<br /> 6 PGII Regulated Medical Waste,n oz., Cu R
<br /> Cu Ft
<br /> 3.Generator's Certification:11 hereby declare that the contents of this consignment are fully and accurately TOTALS ► Cu Ft
<br /> d above by the proper shipping name,and are classified,packaged,marked an!2m
<br /> and
<br /> a respects In proper condition for transport according to applicable internabonal ental r lations"
<br /> P tednyped Name A –t 6
<br /> SPORTER 1 ADDRESS Phone#:
<br /> cc: si:el:xcycle, Inc. This is a Th o gh shig ent
<br /> a.w 4135 W. Swift Ave Applicable Peanut Numbers:
<br /> gi rr Hauler Reg# 3400
<br /> <a Freano,CA 93722
<br /> u,
<br /> a TRANSPORTERIDERTIFICATIOPIcelpt of med,cal waste as descri above
<br /> Prtntflypa Name Signature Date I(
<br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDR Phone#.
<br /> NAppllcabie Permit Numbers•
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above
<br /> PnnVType Name Signature Date
<br /> w w S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS- Phone#
<br /> o, Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIRGATION:Receipt of medical waste as described above
<br /> – Print/lype Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Dastgnated Facility. 88.Alternate Facility ®8C.Alternate Facility: El 8D.Alternate Facility.
<br /> ,J Stetfcycle,Inc. Sterlcycle,Inc. Sterlcycle,Inc. S ricycle,Inc.
<br /> 6�Ai,-S' dttAat N.Foxboro Drive 1661 Shobn D1l9 3140 N 7th Streettrfy
<br /> Fresno,CA�9'MCLA�VE N ilii Salt take,UT 84054 Hollister,CA 95023 Kensas City,KS 66116
<br /> I– (866)7�gT�?ANNE ORTI ( 6)783-7422 (866)783-7422 (866)783-7422
<br /> W TSIOST22 3 8-JA-36 TS/OST 83 TWOST 26
<br /> ,,`•' JAN 04 20it;
<br /> TR FACILITY:I certify that I have een authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> resat ed t e eboxe indica�tedd�Wastes In accordance with the requirement outlined In that authorization.
<br /> Prin pe Name /� Signaturete
<br /> Da
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