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04* Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.600-424-9M STANDARD MANIFEST 001.03.21•NOCA
<br />•' Route fit 125 — 9 CUSTOMER NO. 21132 MDFROOPB97
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:Dwain Baughman 1 ll Jj J` III
<br />RXVV/SGMF MEDICAL PLAZA
<br />2505 W HAN AER LN
<br />STOCKTON, CA 95209- 2839
<br />(209) 521.8087 9/16/2021
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<br />CUSTOMER NUMBER 468-760 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINERTYPE
<br />2C. NO. OF
<br />21), VOLUME
<br />CONTAINERS
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />KRR2 - Slo System Wtlealt Flack 48 CUFT
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<br />62, PGII Regulated Medical Waste, n.o.s.,
<br />KRR3 - 910 Systems Wheeled Rack (52 CUFT)
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<br />UN3291, Regulated Medical Waste, n,o,s„
<br />6.2, PGII
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu I
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />6.2, PGII
<br />Cu i
<br />UN3291 Regulated Medical Waste, n,o.s„
<br />6.2, PGII
<br />Cu I
<br />UN3291 Regulated Medical Waste, n.o.s,,
<br />6.2, PGII
<br />Cu I
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />RX Bios terns Cardboard Box 4.2 cu 19)
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<br />UN3291 Regulated Medical Waste, n,o.s„
<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 I► Cu I
<br />described above by the proper shipping name, and are classllled, packaged, marked and labelled/placarded, and
<br />are In all r roper condition for transpo�rt1acecoorrding to applicable International and natio vernmenfaI regula Ions"
<br />nt Name Slgnature Data
<br />4. TRANS R7ER 1 A ESS: Phone N: )733-7422
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<br />Stetic cle, Inc. is a through Shipment Applicable Permit Numbers:
<br />4135 W. SwtRAue Hauler Reg#3400
<br />E S Fnesno,CA93722
<br />Q TRANSPORTER CERTIFICA ION: Receipt of medical waste as desc
<br />oF� PrinMpe NameS��
<br />Signature Dale
<br />5, INTERMEDIATE AN R 2 /TRANSPORTER 2 ADDRESS: Phone N;
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Dale
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
<br />g Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER !TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
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<br />6A. Designated FacllltY:
<br />Sterlcycle,Inc, (Autoclave)
<br />4 13 6 W Swift Ave
<br />Fresno, CA 93722
<br />(986)783-7427
<br />TWOS°t-22
<br />ea. Alternate Facllity:
<br />Stericycle, Inc. (Indnerator)
<br />90 N, Foxboro Qhve
<br />North Salt lake, UT 84054
<br />(801)936-t17i
<br />3A-4481JA-36
<br />0C, Alternate Facllity:
<br />Stericycle, Inc. (Autoclave)
<br />1661 Sholton Drivo
<br />Holllster, CA 95023
<br />(86G)7894422
<br />T810S'17--83
<br />eU,ARemare r acmry:
<br />Covanta Marlon, Inc
<br />G�, obt;ro ftikd<fkradINR
<br />a8 � BRs!1'WdMT51Ietn,U;l c
<br />Perrnitt90-12 3 42011
<br />wastdA%nld`thAb I, liave
<br />)�• l,ltc/r
<br />(5 03) 393-0 00
<br />Dale 110M)1r
<br />`EATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical
<br />-eived the above Indicated wastes In accordance with the requirement outlined in that authorization.
<br />PrinMpe Name
<br />Signature
<br />Transferred containers
<br />Transferred _ cantalners,
<br />ou A to : Brooks, OR
<br />cu A to : N. Sah Lake, LIT
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