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0�r� Stericycw IN CASE OF EMERGENCY CONTACT; CHEMTREC 1.800-424-9300 STANPAHU MANIFESI UUI-IJ3•21•NUL'A
<br />Route #: 125 — 9 CUSTOMER NO. 21132 MDFROOP761
<br />1- Generator's Name- Address and Telenhone Number
<br />Transferred _ containers, cul # to : Brooks, OR
<br />Transferreld containers, ___ _ cu A to, N. Safi Lake, LIT
<br />ATTN:Dwain Baughman
<br />RXViSGMF MEDICAL. PLAZAI
<br />2505 W HAIAMER LN
<br />STOCKTON, CA 95209- 2839
<br />1-6097
<br />8/19/2021
<br />CUSTOMER NUMBER GENERATOR'S REOISTRAnDN N
<br />2A, DESCRIPTION OF WASTE
<br />CONTAINERTYPE
<br />2C. NO, OF
<br />20. VOLUME
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />CONTAINERS
<br />6.2, PGII
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS Ill
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<br />described above b t oper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all cis I e on r transport according to applicable International and Hell overnm ntel regulations."
<br />P nt Name Signature ADate
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<br />4. TRAN RTER 1'A ESS;
<br />Phone N:
<br />I
<br />Per f bars:
<br />bars:
<br />steel k, Inc. This Is a Through Shipment
<br />cyc
<br />u
<br />Applicableu
<br />4135 W. SwlttAve
<br />Hauler Reg# 3400
<br />Fresno CA 93722
<br />TRANSPORTER CERTIFICAt1ON: Receipt of medical waste as describe
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<br />Print/Type Name Signature
<br />Date 1
<br />5. INTERMEDIATE HAND ER 2/TRANSPOR 2 ADDRESS;
<br />Phone 4:
<br />Applicable Permll Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />Print/Type Name Signature
<br />Dale
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone N:
<br />Applicable Permit Numbers;
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinVType Name Signature
<br />Dale
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Fact IIty: SEI. Alternate Facility: 8C. Alternate Faclllty:
<br />14 8D. Alternate Facility:
<br />Sterlcycle, Inc. (Autoclave) Sterlcycle, Inc. (Indnerator) Sterlcycle, Inc. (Autoclave)
<br />4136 W. Swift Ave 90 N. FoXbDrive 1561 Shelton Drive
<br />Covantf
<br />�1135uI�19R t,ight
<br />r�oro
<br />Fresno, CA 93722 North Salt Lake, UT $4064 Hollister, CA 95023
<br />Brooks, OR 9� U aleln,L'
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<br />(ag6)7aa-742z (901)935-1171 (866)783-7422
<br />78IOST22 3A448I1A-96 TSI05783
<br />(605)393- 0
<br />Permit# G
<br />01
<br />TREATMENT FACILITY: I certlfy that I have been authorized by the applicable stale agency to accept untreated
<br />medical wastes anif t I jia�� �• U
<br />received the above Indicated wastes In accordance with the requirement outlined In that authorization.
<br />',�-.�4�r.r;,,
<br />Printrrype Name SignatureDate
<br />Transferred _ containers, cul # to : Brooks, OR
<br />Transferreld containers, ___ _ cu A to, N. Safi Lake, LIT
<br />
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