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IVIi~IJIK;AL WAtiTETHACKINU FORIv1 NUIVIEER <br />INC F EMERGENCY CONTACT: CHEMTREC 1.800424-9300 STANDARD MANIFEST 001 -10.06 -STD <br />Rou#: 123 .. 4 CUSTOMER NO. 21132 0 MDFROOKGSV <br />i'Genermtdr's Name,Address and Telephone Number <br />�Rrym9 a 11111111111111111111111111111111111111111111111111111 <br />GXLL <br />MD3:rin C NT R i <br />161.7 N CA`l,:EF0l iIJIA ST <br />521C1CiC` ow, CA 96204- 6.1.7 <br />(209) 451-9031 4/17/2018 <br />lftl=NtiM6ER 6111852-001 GENERATOR,s REGIMAVON # <br />. DESCRIPTION OF WASTE <br />20. CO_ NTAiNER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />3291 Regulated Medical Waate, R ms., <br />TH04 — 28 Gal Tub (Bio) (3.7 Cu ft) <br />CONTAINERS <br />Covanta Marlon,ino <br />, palf <br />90 N. Faber l Drive <br />1551 Shabn ON* <br />Cu Ft <br />3291 RegulatodModlcaiWaste,n.cs., <br />PGl( <br />TB49 — 37 CTub (Bio) {h.9 cu it} <br />2t1 <br />Hoilleter, CA 55023 <br />Elroohm, Oil 97305 <br />(866)783+7422 <br />(801)M 1171 <br />(866)783-742' <br />Cu Ft. <br />3291, Reptdatad Medical Waste, n.0 s., <br />PGII <br />- alA Gal Tub {Bio} {5.4 ctx it} <br />TSIOST 83 <br />Permit # 364 <br />s Cu Ft. <br />291 Regulated Medical Waste, 0.0.61, <br />TB21» f } /Tp15- f } jTylS_ f ) 20 Gal Tub {2.7cErFT} <br />Cu Ft. <br />3291 Regulated Medical Waste, n.e.s., <br />Cu Ft. <br />3291 Rtioulated Medical Waste, mo.s., <br />P41) <br />W343- { ) /WP43-- ( ) /VC43-- () foal Tub (5.7CUFT) <br />Cu Ft. <br />3291 'Regulated Medical Waste, n.o.s„ <br />, poll _ <br />KR - Biosystems Cardboard Box (4.3 cu ft) <br />Cu Ft. <br />32911 f 9tigulated Medical Wade, n,o s., <br />�r <br />Cu Ft <br />3291, fieaulated Medical Waste, 0.0.9.1 <br />PGIi <br />Cu Ft. <br />Generator's Certification; "I hereby declare that the contents of this consignment are fully and accurately TOTALS )► <br />--fkn.1 nhn.,n h,, fkn nw — ni.inninn new.- —1 -.., nt--nlFlnd--nt.nnn.i ...0.1....1 --.i 1-G-]1....11 . 1aa...1 .....1 <br />Cu Ft. <br />4135 W. S'wjgt AVG <br />r-reanorGA 93722 <br />IANSPORTEk <br />nIMpe Name __ <br />NTERMEDIATE <br />medical waste as described <br />2 ADDRESS: <br />Signature <br />TERMEDIATE HANDLER ]TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Hauler Reg# 3400 <br />Date 71 0 <br />Phone #. <br />Applicable Permit Numbers: <br />nMps Name Signature Date <br />NTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone M. <br />Applicable Permit Numbers: <br />TERMEDIATE-HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />riMpo Numo Signature Date <br />)ISCCHEPANCY INDICATION <br />I <br />8A. Designated racliity: <br />813. Alternate Facility: <br />8C. Alternate Facility: <br />❑ 8D. Alternate Facility: <br />-�Icyala, Ina. <br />Stericycle. Inc. <br />Slerit ycle. Inc. <br />Covanta Marlon,ino <br />4135 W. S',MfEA" <br />90 N. Faber l Drive <br />1551 Shabn ON* <br />Q68131`001(t8ke Road NE <br />Frpsnoi CA 93722 <br />North Sail Lake, LIT $4854 <br />Hoilleter, CA 55023 <br />Elroohm, Oil 97305 <br />(866)783+7422 <br />(801)M 1171 <br />(866)783-742' <br />(505)313-088D <br />'iWOST 22 DAA .A%NE olu <br />3A-448/94-36 <br />TSIOST 83 <br />Permit # 364 <br />1EATMENT FAC rt t I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />;elved the abo a in accordance with the requirement outlined In that authorization. <br />1tliype Name Signature Date <br />randemed cottatnem, ouftto,: <br />: <br />ORIGINAL <br />