|
Stericyde°
<br />1N CASE OF EMERGENCY CONTACT: CHkMTREC 1.800-024-9300 STANDARD MANIFEST 001.03.21-NOCA
<br />ROLI[e fP 705 -12 FUSTOMER NO. 21132 MDTKOOOGCI:
<br />1. Generator's Name, Address and Telephone Number
<br />,911
<br />DwainCAL
<br />I(�Iisl{I ��I �I�
<br />RXt111A GMT MEDITTIIJ:
<br />PLANA 1 SII IE�II�il 1
<br />tl
<br />2505 W HAMME=R LN
<br />12/2/202'1
<br />STOCKTON, CA 95209-2839 (2.09) 521-6097
<br />6131468-750
<br />CusTOMER NUMBER GENERATOR'S REGISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />28• CONTAINERTYPE
<br />2C. NO. OF
<br />2D, VOLUME
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />U6.N3291
<br />r
<br />KR'R2'-(Phnn-n) 2 Shelf VAleeled Rack (4S Cuft.)
<br />CONTAINERS
<br />Cu
<br />62.PGIIRegulatedMedlcalWasle,n",
<br />KRR3-(Phann)3Shell"A"neeledRack (52Cult,)
<br />Cu
<br />CC
<br />RegulaledMedlcalWasle,n.o.s„
<br />RY-(Pharrn)_,--_ Coal, Con-uclated Box, (4122 CUR.)
<br />p
<br />623PGII291
<br />Cu
<br />Q
<br />62,PG11IRegulated Medical Waste. n,o.s„
<br />R-(Pharrn)__,Gal,'CDrrugatedBo?'(4.32CLtft,)
<br />�
<br />Cu
<br />LU
<br />UN3291 Regulated Medical Waste, mo.s.,
<br />Z
<br />6.2, PGII
<br />. Cu
<br />Lu
<br />N32911 Regulated Medical Waste, n,o,s.,
<br />6
<br />Cu
<br />UUN32911I Regulated Medical Waste, n.o.s.,
<br />Cu
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />6.2, PGII
<br />Cu
<br />UN3291 Regulated Medical Waste, n,o,s„
<br />6,2, PGII
<br />C
<br />3. Generator's Certification: 'I hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />2S.L Cu
<br />described above by the proper Shipp g name, and are class ackaged, marked and labelled/placarded, and
<br />are In all �dspects In proper Conditl for trans ort accords to applicable International and national governmen gulatlons."
<br />Printed/Typed Name—Signatur
<br />4. TRANSPORTER 1 ADDRES
<br />Phone M:9) 294-7114
<br />stericycle, til . 11115 is D Thr01 fl1 Cilli 111011t
<br />Applt ermitNumbers:
<br />2
<br />7275 R A Bridti(Jord Rd.
<br />TS/OST-80
<br />°
<br />Stockton, CA 95206
<br />i a
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as des
<br />2Z:�KPD3Date
<br />PrinVType Name Signature
<br />`"`MIA*
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />N:
<br />]rr
<br />Applicable Permit Numbers:
<br />S
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />Print/Type Name Signature
<br />Dale
<br />13
<br />B. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS;
<br />Phone b;
<br />Applicable Permit Numbers:
<br />i�3 Z
<br />S
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />—
<br />PrinvType Name Signature
<br />Date
<br />7, DISCREPANCY INDICATION
<br />z
<br />8A, DM BB. Alternate Facility: 8C. Alternate Facility:
<br />80. Alternate Facility:
<br />,.°C1CrfGle��r���ApCleVe)-terlCyCle, Inc. (Incinerator) Steriayole, Inc. (Autoclave)
<br />Covanta "/larivn, lac
<br />7475 Rf1 n gaFurd Rd. 130 N. Faiovro Driw 2775 E. 28th St,
<br />4E50 E3rool<fake Read PIE
<br />_
<br />StuolctL4 A C� � 'ij1. North Salt Lake, UT 84058 Vernon, C:A Ot]05S
<br />E7roolts, OR 07305
<br />(202)2 1 301)93P 1171 (806)783-7422
<br />(505)303-0880
<br />g
<br />TSlt7ST 80 r1- 1�16/JA 39
<br />Penrut # 389
<br />TREATIQTIL I rti t ave been authorized by the applicable state agency to accept untreated
<br />medical wastes and that I have
<br />-
<br />received th wastes In accordance with the requirement outlined In that authorization,
<br />Prinlrlype Name Signature
<br />Dale
<br />
|