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V,%-.* Stericycle• IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-4249300 STANDARD MANIFEST 001•03.21•NOCA
<br />_ CUSTOMER N0, 21132
<br />1, Generator's Name, Address and Telephone Number
<br />Transfand contalnem, cu t to: Brooks, OR
<br />Transfermd colMatnem, til t to : N. Salt Lake, LIT
<br />ATTN:Merie NII IIII�IIIIII�I I I II 11II�I1111lII�InI �!I (��'
<br />SGNF STOCKTON MEDICAL. PLAZA 1
<br />2505 W HAWER LN
<br />STOCKTON, CA 95208-2839
<br />(209) 422-7678
<br />V26M0211
<br />CUSTOMER NUMBER GENERATOR'S REOISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />CONTAINERTYPE
<br />2C, No, of
<br />2D, VOLUME
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />CONTAINERS
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<br />3, Generator's Certlllcatlon: 'I hereby declare that the contents of this consignment are fully and accurately TOTALS 10-
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are In all respp.0.]R proper on for transport according to applicable International and national` govern, tairegufations"
<br />Nem I nature
<br />4, TRAN ORTER 1 AD ESS: ___....
<br />Dete
<br />aint
<br />a N:
<br />Applicable PertnnKveA4422
<br />Stec!cycN, Inc. ❑ This Is a Through Shipment
<br />E
<br />W. SwIAAve
<br />Hauler Reg# 3400
<br />E135
<br />CER�fCRT10N:� X41 of medical waste as descrlb�d aba.
<br />zTRANSPORTER
<br />' -�
<br />PrinVType Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 2! TRANSPORTER 2 ADDRESS:
<br />Phone N:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical wasle as described above.
<br />PrinVType Name Signature
<br />Dale
<br />e, INTERMEDIATE HANDLER a /TRANSPORTER 3 ADDRESS:
<br />Phone 11:
<br />Applicable Permit Numbers:
<br />s
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />�z
<br />PdnV7ype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />80. Altemet• Faelllty:
<br />A. Deelgnated Facility: 89, Alternale Faelilty: El 8C, Alternate Faeillty:
<br />�
<br />�3bertcycle, Inc. (Autoclave) Stelicycle, Inc, (Incinerator) Sterlcycle, Inc, (Autoclave)
<br />CovarTta Marlon, Inc
<br />41 Ali W >" wO AvA 90 N. Foxboro ON* 196 t RhANgn ISA
<br />4999 QmAldn" RARd Nro
<br />R2 North Salk Lake, UT 84th HoVAder, CA 95023
<br />Brooks, OR 97305
<br />$W
<br />(CRIpoo-1171 (5155)78'-7472
<br />T 3A-44 B/,1A-36
<br />(608)3!) -nano
<br />TS/OST 83
<br />Pe mit * 364
<br />AUG 26 2021
<br />iP-11
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated
<br />medical wastes and that I have
<br />received bo Indicated wastes In accordance with the requirement outlined In that authorization.
<br />��k�
<br />PrtnVType Name Signature
<br />Date
<br />Transfand contalnem, cu t to: Brooks, OR
<br />Transfermd colMatnem, til t to : N. Salt Lake, LIT
<br />
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