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MEDICAL WASTE TRACKING FORM NUMBER
<br /> i� Stericycle INC E [lG Y CONTE :CHEMTREC 1-800-424-9300 STANDARD MANIFEST ool-io-o6-STD
<br /> � ' � - CUSTOMER NO,21132 MD>.'ROONZZV
<br /> 1.Generator's Name,Address and Telephone Number
<br /> 111111111111111ATTN:Crysta) Molina IIN 1
<br /> VAN TRAM, OR RICK DDS INC-
<br /> 1007 S MAIN ST
<br /> h"TFCA, CA 915337-55703
<br /> (209) 823-9218 10/2312020
<br /> CUSTOMER NUMBER 6084572-001 GENERATOR'S REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 213. CONTAINER TYPE 2C. NO.OF 2D. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., TB04 28 Gal Tub //BIO 3.7 cu ft) CONTAINERS
<br /> -
<br /> 6.2,PGII (Bio) ( ) Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., TB49_37 Gal Tub (Bio) (4.9 cu ft)
<br /> 6.2,PGII Cu Ft.
<br /> ¢ UN3291,Regulated Medical Waste,n.o.s., TB 14-44 Gal Tub(Bio) (5.9 cu ft)
<br /> 0 6.2,PGII Cu Ft.
<br /> QUN3291,Regulated Medical Waste,n.o.s., a U
<br /> CC
<br /> 6.2,PGII Cu Ft.
<br /> W UN3291,Regulated Medical Waste,n.o.s.,
<br /> LU
<br /> Z 6.21 PGII Cu Ft.
<br /> 62,PG11 Regulated Medical Waste,n.o.s., W$43-{ )NvP434 )NVG434_ _1 Gal Tub(5.7CUFT)
<br /> Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., KR _Biosystems Cardboard Box 4.3 cu
<br /> 6.2,PGII ( ) Cu Ft.
<br /> 6 232911 Regulated Medical Waste,n.o.s., ` —� I!� Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII Cu Ft.
<br /> 3.Generator's Certification;'I hereby declare 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/placarded,and
<br /> are in all respects in proper c ndifion for trp-isporf= ordfng to appl
<br /> icable international and natfonaf governmental regu s:' (�
<br /> Printed/Typed Name ►3rtiw "`�� Signature Date d ri'�c `�
<br /> th
<br /> ¢ 4.TRANSPORTER i ADDRESS: Phone : »
<br /> Lu Sterscyrie, Inc. ❑ This is a Through Shipment Applicable Permit Numbers:
<br /> 4135 W. Swift Awe Hauler Re 3400
<br /> 2 y F 'resn 937
<br /> a as TRANSPORTER IC t edical waste as descri }-y
<br /> ~ Print/Type Na Si Date
<br /> 5.INTE TE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> N15 Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER(TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 6,INTERMEDIATE HANDLER 3 1 TRANSPONTER 3 ADDRESS: Phone 4:
<br /> 3 Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name. Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> SA.Designated Facility: 88.Alternate Facility, ❑8C.Alternate Facility: ❑ 8D,Alternate Facility:
<br /> I Sterlaycle,Inc.(Autoclave) Sterlcycle,Inc.(Incinerator) Stericycle,Inc.(Autoclave) Covanta Marion,Inc
<br /> ES 4136 W,54RAYe 90 N.Foxboro DrN* 1061 Shelton Drl" 4364 BrooMake Road NB
<br /> LL Fresno,CA 93722 north Safi Lake,UT 84354 Hollister,CA 95023 Brooks,OR 97305
<br /> z (866)783-7422 (80t)936r1ll71 (856)783-7422 (505)393-0890
<br /> UJI TSIOST 22 3A 448fJPr36 TLE
<br /> SIOST 83 Permit*364
<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 /> H received the aboveIndicatefdl {wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type Name9��I 23 2029 Signature Date
<br /> Transterred containers, cu ft to : rooks, OR
<br /> Transferred containers, cu It to : N.Sak Lake, UT
<br /> I '
<br /> ORIGINAL
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