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795tericycW IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800.424.93DO STANDARD MANIFEST ODI.03.21•NOCA
<br />Route #: 125 — B CUSTOMER NO. 21132 MnF'RQOP760
<br />! d TREAT fiAi 1 cerlity that I have been authorized by the applicable slate agency to accept untreated medical wastes and that I have
<br />receive *V4 I(lrNf6��ted wastes In accordance with the requirement outlined In that authorizatlon,
<br />Print/Type
<br />Signature
<br />Date
<br />Transferred _ containers, _ _ cu tt to : Brooks, OR
<br />Transferred eontalners, _ eu tt to : N. Salt Lake, UT
<br />ATTN:Mada 11111111111111 IN
<br />SGMF STOCKTON MEDICAL PLAZA. 1
<br />2505 W HAMMER LN
<br />STOCKTON, CA 95209-2839 (90A) AV -7578 8/19/2021
<br />CusTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />CONTAINER TYPE
<br />2C, NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medlcal Waste, n,o.s,,
<br />CONTAINERS
<br />6.2, PGII
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<br />UN3291 Regulated Medical Waste, n,o.s„
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<br />TU21 X154( yTY15{.,_„_ )20 Gal Tub(2,7CUFT
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<br />UN3291 Regulated Medical Waste, n.o.s.,
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<br />3, Generator's Certification: "I hereby declare that the contents of thls'consignment are fully and accurately TOTALS / Cu I
<br />described above by the roper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />mental regulations:'
<br />are In all r o dri on for transport according to applicable International and nnnatur.
<br />edriMed/T Nam Dete
<br />4. TRA ORTER RESS: Phone#:
<br />(S�i -7422
<br />hers:
<br />cy� ❑ This is 8 Through ShiQmertt Applicable Permit u bars;
<br />Stets le, Inc.
<br />4135 W. SwiRAue Hauler Reg# 3400
<br />uai
<br />Fresno CA93722
<br />TRANSPORTE ERTIFICA� N: Receipt of medical waste as de ed a
<br />Q
<br />~
<br />Pflnt/Type Name signet-, Date
<br />5. INTERMEDIATE AND R 2/TRANSPORTER 2 ADDRESS: Phone q:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />B. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone #:
<br />s
<br />Applicable Permlt Numbers:
<br />39
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinVType Name Slgnalure Date
<br />7, DISCREPANCY INDICATION
<br />8A. Designated Faclllty:
<br />Lj 85, ANemate Facility:
<br />Lj 8C, Aflemale Facility:
<br />81). Alternate Facillty:
<br />Stedcycle, Inc. (Autoclave)
<br />Sterlcycle, Inc. (Indnerator)
<br />Stericycle, Inc. (Autoclave)
<br />Covanta Marlon, Inc
<br />4135 W Swift Ave
<br />90 N, Foxboro DrNa
<br />1651 Shelton Drive
<br />4850 Brooklake Road NE
<br />Fresno, CA 93722
<br />North Salt Lake, UT 84054
<br />Hollister, CA 95023
<br />Brooke, OR 97305
<br />I
<br />(868)783.7422
<br />(801)931;-1171
<br />(886)783-7422
<br />(505)393-0890
<br />UM VEo 1z
<br />3A-448/JA-38
<br />TWOST-83
<br />Permlt # 394
<br />! d TREAT fiAi 1 cerlity that I have been authorized by the applicable slate agency to accept untreated medical wastes and that I have
<br />receive *V4 I(lrNf6��ted wastes In accordance with the requirement outlined In that authorizatlon,
<br />Print/Type
<br />Signature
<br />Date
<br />Transferred _ containers, _ _ cu tt to : Brooks, OR
<br />Transferred eontalners, _ eu tt to : N. Salt Lake, UT
<br />
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