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Stericycle!
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-424.9300 STANDARD MANIFEST 001.03-21-NOCA
<br />Route #: 125 — 12 CUSTOMER NO. 21132 MDFROOP54Q
<br />Transhrrerf—' containers, �acu t to : Brooks, OR
<br />Transferred carttalners, cu t to : N. Salt Lake, UT
<br />1. Generator's Name, Address and Telephone Number
<br />ATTNDwaln BouDi>!man
<br />RXWSSGMF MEDICAL PLAZA 1
<br />2505 W H44ER LN
<br />STOCKTON, CA 95208- 2839
<br />209 821-8087
<br />8/5/2021
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINER TYPE
<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 Certification: 1 hereby declare that the contents of this consignment are fully and accurately TOTALS 1110-
<br />—51Cu I
<br />described above by the proper shipping name, and are classified, packaged, marked and labelledi#facarded, and
<br />are in all re er con to tans rt according to applicable International and nation ernmental regulations
<br />P nted/Typed NemL 1 nature
<br />Dete
<br />4. TRANS RTER 1 A ESS;
<br />one N; 888}783-7422
<br />sterlowle, Inc. This is a Through Shipment
<br />Appllceble Perm t Numbers:
<br />4135 W. SWR Ave
<br />Hauler Reg# 3400
<br />Fresno,CA93722
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as describ a
<br />Print/Type Name Signature
<br />Date
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone N;
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />PrinMpe Name Signature
<br />Date
<br />6, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone N:
<br />rt
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Applicable Permit Numbers:
<br />Print/Type Name Signature
<br />Date
<br />7, DISCREPANCY INDICATION
<br />SA. Designated Fsclltty: 89. Allemate Facility; 8C. Altemate Facility;
<br />80. Ahemat• Facility:
<br />Sterlcycle, Inc, (Auboelasve) Stericycle, Inc. (Indnerstor) Stericycle, Inc. (Autoclove)
<br />4135 W 9WIltAve 90 N. F040M DrNe 1551 Shelton Drive
<br />4850 g �nAec•
<br />Wl 31
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<br />Fresno, CA 93722 North Solt Lake, UT 84054 HolllsWr, CA 85023
<br />Brooke, OR 97305
<br />(866)783-7422 (801)936-1171 (866)783-7422
<br />s1021
<br />(60AWMRATED
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<br />TWOST 22 3A-448/JA-36 TS/OST-83
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<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated
<br />received the above Indicated wastes In accordance with the requirement outlined in that authorization.
<br />medical wfsk���ve
<br />110001653434
<br />PflnMpe Name (Signature +��
<br />Date
<br />Transhrrerf—' containers, �acu t to : Brooks, OR
<br />Transferred carttalners, cu t to : N. Salt Lake, UT
<br />
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