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• Stericycle`
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001.03.21 •NOCA
<br />CUSTOMER NO 21'132
<br />1. Generator's Name, Address and Telephone Number
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<br />Transferred containers, cu 1R to : Brooks, OR
<br />Transhl'nd containers, cu t to : N. Sak Lake, UT
<br />ATTN:Dwain Baughman
<br />RXWSGMF MEDICAL PLAZA 1
<br />2505 W HAMvER LN
<br />STOCKTON, CA 95209- 2839
<br />(200)6216007
<br />9428120111
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />CONTAINERTYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />CONTAINERS
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu
<br />X
<br />UN3291 Regulated Medical Waste, mo.s.,
<br />0
<br />62, Pall
<br />Cu F
<br />a
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />/1
<br />V
<br />//
<br />(0
<br />6.2, PGII
<br />-' r
<br />Cu F
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<br />UN3291 Regulated Medical Waste, mo.s.,
<br />6.2, PGII
<br />Cu F
<br />tZ
<br />N3PG11I Regulated Medical Waste, n,o.s.,
<br />/�,
<br />6
<br />-� �-�{
<br />Cu F
<br />UN3291 Regulated Medical Waste, n,o.s„
<br />6.2, PGII
<br />Cu F
<br />UN329i Regulated Medical Waste, n.o.s.,
<br />62, PGII
<br />Cu F
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2; PGII
<br />--
<br />Cu
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 1110�
<br />Cu F
<br />described above by the proper shipping name, and are classified, packaged, marked and label led/pfacarded, and
<br />yarn tat regulation
<br />are In all rqqpaGLs In proper c to for transport according to applicable International and nation s"
<br />ICrl"t-w ped Nam SI nature
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<br />4, TRA 8PORTER 1 AD ESS:
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<br />Phone M:
<br />Applicable Per(M)W-7422
<br />-•-••� ew This is a Through Shipment
<br />4135
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<br />WsM+itl�AFre
<br />H auler Reg�r 3400
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<br />pppp 3722
<br />CEI�CA : Receipt of medical waste as descri d abov,•-
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<br />ZTRANSPORTER
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<br />PrInMps Name Signature
<br />Date
<br />S. INTERMEDIATE 1404DLYk 2 / TRANSPOR R 2 ADDRESS:
<br />Phone k:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print[fype Name Signature
<br />Dale
<br />6, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone M:
<br />Applicable Permit Numbers:
<br />3
<br />3
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pflnt/Type Name Signature
<br />Dal
<br />7. DISCREPANCY INDICATION
<br />8
<br />8A, Designated Facility; 80, Alternate Facility: E] 8C. Alternate Facility:
<br />SD. Alternate Facility:
<br />I
<br />i
<br />Stericycle, Inc. (Autoclave) Stericycle, Inc. (Indnerstor) Stericycle, Inc, (Autoclave)
<br />Covents Marion, Inc
<br />4136 W. 9►MftMilli 40 N, Foxboro DrtVe 1661 Shelton Drive
<br />4aig�q¢,E
<br />i
<br />Freeno, CA 83722 North Salt Lake, LIT 84064 Hollister, CA 95023
<br />4050DftRR &Affl AMM, OR 973
<br />i
<br />(866)783-7422 (801)836-1171 (866)783-7422
<br />(5051393-0890
<br />PA0
<br />TS/08T 22 3A-448/JA-36 TSIOST 83 Pe t
<br />2021
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical was`Q� thatJ•h ve
<br />received the above Indicated wastes in accordance with the requirement outlined in that a thorization.
<br />1a �f{� ;) i
<br />>t,. J;.rrrro
<br />PrinVType Name Signature
<br />Date (r,(1?�
<br />./J1q !J'
<br />Transferred containers, cu 1R to : Brooks, OR
<br />Transhl'nd containers, cu t to : N. Sak Lake, UT
<br />
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