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0i-0 Stericycle! IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-424.9300 STANDARD MANIFEST 001.03-21-NOCA
<br />CUSTOMER N0, 21132 _
<br />1. Generator's Name, Address and Telephone Number
<br />Transferred —5,�contalners, cu i to : Brooks, OR
<br />Transferred — contalners, cu R to : N. Sak Lake, LIT
<br />AT M:[Main Baughman
<br />RXWSGMF MEDICAL PLAZA
<br />2505 W HAMPER LN
<br />STOCKTON, CA 95209-2839
<br />(20 9) 621 Goo;
<br />Bill 24021
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION M
<br />2A. DESCRIPTION OF WASTE %j I
<br />W.-r%JLP-750CONTAINER7YPE
<br />20. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.os.,
<br />CONTAINERS
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<br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accurately TOTALS II
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<br />described above by the proper shipping name, and are classifled, packaged, marked and labelled/placarded, and
<br />are In all respects In proper condition for transport according to applicable International and national governmental regula ns."
<br />Prinled/T Name -Signature
<br />Date Z
<br />4, TRANSPORTER 1 AI)DRESS; I
<br />Inc. Is Through Shipment
<br />Phone 11: /QRR�7Q�
<br />Applicable Pern11r1ahhbe43-7422
<br />Stericyck, This a
<br />Ave
<br />a
<br />4135 WW Swift
<br />Hauler Reg# 3400
<br />i
<br />TRANSPORTER C %93722
<br />Receipt of medical waste as described above,
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<br />PrInVType Name r e
<br />Date Z Z/
<br />s. INTERMEDIATE NDLER 2 /TRANSPO TER 2 ADDRESS:
<br />Phone ff;
<br />Applicable Permit Numbers:
<br />i
<br />E
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PdnVType Name Signature
<br />Dale
<br />6, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers;
<br />22
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />i
<br />Print/Type Name Signature
<br />D to
<br />7. DISCREPANCY INDICATION
<br />_
<br />A. Designated Facility: 68, Alternate Facility: 8C, Alternate Facility:
<br />8D, Alternate Facility:
<br />3
<br />Stelicycle, Inc. (Autoclave) StedcycleInc. (Indnerator) Sterieycle, Inc. (Autoclave)
<br />41RWM W
<br />WHOM Inc.
<br />S0
<br />[
<br />�M �,vA 90 N. FOX60ro Drive 1 Ariii RhAUn PrivA
<br />tlt11611ili*IR"# §
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<br />Ft~W, OA "792 Morkh tk G.L*e, UT 84MA Hc,)Ha►rr, CA 5 602 3
<br />t315 (001)936-9171
<br />Brooks, OR 973973065(t%5a)7-74Z2
<br />(15!515)7113-7422
<br />TSIOST 22 3A-448/JA-38 TS/4ST 83
<br />=91 -A 90
<br />'1Cn21
<br />5
<br />INC(NER�&T
<br />TREATMENT FACILITY: I certify that I have been autlPtorized by the applicable state agency to accept untreated rnedlcal was a ave
<br />-
<br />received the above indicated wastes In accordance with the requirement outlined in that authorization,
<br />503 393_ n
<br />PrInUTypeName Signature
<br />Date 1100016534:4
<br />Transferred —5,�contalners, cu i to : Brooks, OR
<br />Transferred — contalners, cu R to : N. Sak Lake, LIT
<br />
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