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<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-4249340 STANDARD MANIFEST 001.03.21•NOCA
<br />ROut'R.- #'. 123 — 15 CUSTOMER NO. 21132 MDFROOPBSE
<br />Transferred containers, cu t to : Brooks, OR
<br />Transferred contalneis, _ cu t to : N. Sah Lake, UT
<br />i. taeneraTor's name, gaaress ana lelepnone tvutnoer
<br />AT-INNail is I
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<br />SGMF STOCKTON MEDICAL PLAZA 1
<br />2605 W HAMvER LN
<br />STOCKTON, CA 96209-2839
<br />'
<br />(209)422-7578
<br />8/31/2021
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C, NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />CONTAINERS
<br />6,2, PGII
<br />Cu I
<br />8 2, PGII 3291 Regulated Medical Waste, n.o,s.,
<br />T849 - 37 Gal Tub 131o) (4.9 cu t)
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<br />P
<br />UN3291
<br />2, PGII Regulated Medical Waste, n.o.s.,
<br />TB 14 -44 Gal Taub lo) (5.9 cu A
<br />Cu I
<br />a
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />T8214--M15{�yTY154-- 120 OaI Tub 2.7CUFT)
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />Z
<br />6.2, PGII
<br />Cu I
<br />5
<br />UN3291 Regulated Medlcal Waste, n.o.s.,
<br />6.2, PGII
<br />4 ai ub 5.7 U
<br />Cu I
<br />UN3291 i) Regulated Medical Waste, n.o.s.,
<br />KR - Bias ems Card and Box 4.3 cu ft
<br />Cu I
<br />UN3291 Regulated Medical Wasle, n.o.s.,
<br />6.2, PGII
<br />Cu I
<br />UN3291, Regulated Medical Waste, Il.o.s.,
<br />6.2, PGII
<br />Cu 1
<br />3. Generator's Certllicatlon: "I hereby declare that the contents of this consignment are fully and accurately TOTALS /
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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 res r i n for transport according to applicable International and national veru ental regulatl s"
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<br />Prt ed/T em I nature
<br />Dat
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<br />4.TRANSP TER 1 RpSS:
<br />Phone 0: )}
<br />Steil b, Inc. [] This Is a Through Shipment
<br />Applicable Per I185u(nb8r3e-7422
<br />.
<br />4135 W. SwifAut
<br />H auler Reg# 3400
<br />N
<br />Fresno,CA93722
<br />TRANSPORTER R" IFICATIO : Receipt oI medical waste as de, ed abo
<br />r
<br />PrinUrype Name Signature
<br />5, INTERMEDIATE HANDIth 2 RANSPORTER 2 ADDRESS:
<br />Date
<br />Phone N:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Typs Name Signature
<br />Dale
<br />6, INTERMEDIATE HANDLER,9 / TRANSPORTER 3 ADDRESS:
<br />Phone N:
<br />s
<br />e°
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Prinl/Type Name Signature
<br />Dale
<br />7. DISCREPANCY INDICATION
<br />Facility: 8B. Alternate Fscllity; E] 8C, Alternate Facility:
<br />8D, Altemate Faclllty:
<br />:.Ignated
<br />ericycle, Inc. (Aubociave) Stericycle, Inc, (Incinerator) Stericycle, Ino. (Autoclave)
<br />Covarb Marlon, Inc
<br />4136 W. WAR Avo 90 N, FOXWO Drive 1661 Shelton Drive
<br />4860 Brooklake Road NE
<br />Fresno, CA 93722 North Soft Lake, UT 84064 Hollister, CA 96023
<br />Brooks, OR 87305
<br />(8Pa (801)936-1171 (8613)783-7422
<br />T1z
<br />(1303)393-0890
<br />T 3A-449I1A-36 TS/OST-83
<br />Pe mit# 364
<br />it
<br />TREATMIAW644LON1 certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above indloated wastes in accordance with the requirement outlined In that authorization,
<br />nn
<br />Prinl/Type N�Tfied"`P, t Signature
<br />Dale
<br />Transferred containers, cu t to : Brooks, OR
<br />Transferred contalneis, _ cu t to : N. Sah Lake, UT
<br />
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