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S"'Ir .„, GENERATOR'S REGISTRATION #
<br />2B. CONTAINER TYPE
<br />11304 Gal Tub (Bio) (3.7 Cu
<br />fri349 - 37 Gal Tub (Bib) (4.9 Cu ft)
<br />j Gal Tub(5.7CLIFT)
<br />KR - Biosysterns caillimand Eto. (4..3 trli 11)
<br />TRANSPORTER 1 ADDRES$:
<br />Stencycie,
<br />4135 kAd. ALM
<br />Fresn9QA 93122..
<br />U This is a Through Shipment
<br />Phone #: Oitib)/U3-f4
<br />Applicable Permit Numbers:
<br />Retlif 3400
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />Phone .
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name
<br />
<br />Signature
<br />
<br />INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />0'4* Stencycle' IN cpsE ?F. EfFIGEnY CONTACT: CHEMTREC 1-800-424-9300
<br />CUSTOMER NO. 21132
<br />IVIti.J1UAL WAS It I HAUKINU I-UHNI NUNII3t1-1
<br />STANDARD MANIFEST 001-10-06-STD
<br />MDFROONZZY
<br />1. Generator's Name, Address andlelephone Number
<br />ATIN:Ciystai Moline
<br />VAN TR.AN , DR RICK DOS INC.
<br />1001 S MN $T
<br />tviANTEtA„ CA 45337- 510.
<br />1III1!VIT111111111111 Mal
<br />A.:.3-0213 1012342020
<br />CUSTOMER NUMBER
<br />2A. DESCRIPTION OF WASTE
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />1JN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.
<br />6.2, PGII
<br />2C. NO. OF
<br />CONTAINERS
<br />2D. VOLUME
<br />Cu F
<br />44 Gal Tub(Sio) (5,9 Cu ft)
<br />jitrIbi„,11rt 16-4( )A Gal I utO ;th-
<br />Cu F
<br />Cu F
<br />Cu F
<br />Cu F
<br />Cu F
<br />Cu F
<br />Cu F
<br />Cu F
<br />TOTALS 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in proper condition for transport according to applicable international and national governmental egulations."
<br />V
<br />A Printed/Typed Name ' •-
<br />Print/Type Name Signature Date
<br />DISCREPANCY INDICATION
<br />Cu F
<br />' Signature Date
<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 />received the above indicated wastes in accofdance with the requirement outlined in that authorization.
<br />8A. Designated Facility:
<br />SterIcycle, inc. (Autociave)
<br />T,o.oft..Avo -
<br />Pmarto, CA S3722
<br />066)783-74122
<br />fstoST-22
<br />El 8B. Alternate Facility:
<br />Stencycle, Inc. (Incinerzkr)
<br />N, FM:44n Dr14
<br />North Salt Lake, UT 84054
<br />(801)13&-1171
<br />3A-44B1A-36
<br />0 8C. Alternate Facility:
<br />Stericycle, Inc, (Autoclave)
<br />1501 StI151u,41 ()Nit
<br />HoIlistsr, CA 9602S
<br />(566)7a3-7422
<br />0 8D. Alternate Facility:
<br />Covanta Marlon, Inc
<br />4550 Broti1401% Road NE
<br />Brooks, OR 97305
<br />(505),,Sg3-01,390
<br />Permit *384
<br />Print/Type Name Signature Date
<br />
<br />onstorod miniamerN, v_o eist)1,4.;cs,,Of
<br />
<br />Damiottoi coniatevs, II to N..LT
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