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<br />Stericycle`
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001.03 -21 -HOCA
<br />ROL110 fir 705-11 CUSTOMER NO. 21132 MDTIC0006Z3'
<br />1. Generator's Name, Address and Telephone Number
<br />ATThl: D>,vain Dauyhrnan
<br />RXVI(ISGMF MEDICAL PLAZA 1 b
<br />2505 W HAMMER LN 12/9/2021
<br />STOCKTON, CA 95209-2039 (209) 02'1-6097
<br />G 1314681-750
<br />CUSTOMER NUMBER
<br />2A, DESCRIPTION OF WASTE
<br />UN3291,, Regulated Medical Waste, n.o.s
<br />UN3291 Regulated Medical Waste,
<br />6.2, PGII
<br />UN3291 Regulated Medical Waste,
<br />6.2, PGII
<br />UN3291 Regulated Medical Waste,
<br />6.2, PGII
<br />GENERATOR'S REGISTRATION N
<br />2B. CONTAINER TYPE
<br />KRR2-(Pharm) 2 ShelfI,Yheeled Rack (46 Cult.)
<br />I-MR9-(Pharm)3 Shelf `J heeled Radk (52 Cuft,)
<br />P'X-(PharrF1)__ Gal, COIYLKj@[C-d BOX (4,32 Cuft.)
<br />RX-(Pharrn)_____ OnI. COlruP�ated BOY (4.32 Cufc,)
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ►
<br />described above by the proper shipping name, and are classified, packaged, marked and labellediplacarded, and
<br />are in all respects In proper condition for transport according to applicable International and national governmental regulations."
<br />2C. NO. OF 2D. VOLUME
<br />CONTAINERS
<br />Printed/Typed Name Signature Date
<br />4. TRANSPORTER 1 ADDRESS: Phone C (20M 2 4-7
<br />Z_�E] This is a Through Shiialtlenl Applicable Permlt Numbers:
<br />E0 7375 R A i3ridueford Rd. TSIO`_ T-20
<br />�°�, Siccklon, CA 95206
<br />E TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />~ PrinLr ype Name Signature Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone ll:
<br />i
<br />Applicable Permit Numbers;
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical Waste as described above.
<br />Print/Typs Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone q:
<br />Applicable Permit Numbers:
<br />s INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrInt/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />❑ 8A. Designated Facility: Lj 8B. Alternate Facility: 5C, Alternate Faculty: So. ANemale Facility:
<br />t StcfIGYGIe, Inc. (Autoclave) Staricy le, Inc. (incinerator) StericYole, Inc. (Autoclave) Covanta Marion, Inc.
<br />t �1 7675 RA Bridgeford Rd. 90 N. Foxboro Drive 2775 E. 26rh St, 4650 Brooklake Road NE
<br />Stockton, CA 952013 North Salt Lake, UT 84054 Vernon, CA 90053 crooks, OI? 97305
<br />(209)2944!14 (301)9313-1171 (6(30)733-7422 (505)393-0890
<br />TS/05T SO 3A1 ?-161JA-J0 Ft mrit r+ 30,1
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above Indicated wastes In accordance with the requirement outlined In that authorization.
<br />PrIntlType Name Signature Dale
<br />Cu
<br />UN3291 Regulated Medical Waste, n.ox.,
<br />6.2, PGII
<br />fY
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6,2, PGII
<br />0
<br />UN3291 Regulated Medical Waste, n,e.s.,
<br />6.2, PGII
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />rZ
<br />0
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />UN3291 Regulated Medical Waste,
<br />6.2, PGII
<br />UN3291 Regulated Medical Waste,
<br />6.2, PGII
<br />UN3291 Regulated Medical Waste,
<br />6.2, PGII
<br />GENERATOR'S REGISTRATION N
<br />2B. CONTAINER TYPE
<br />KRR2-(Pharm) 2 ShelfI,Yheeled Rack (46 Cult.)
<br />I-MR9-(Pharm)3 Shelf `J heeled Radk (52 Cuft,)
<br />P'X-(PharrF1)__ Gal, COIYLKj@[C-d BOX (4,32 Cuft.)
<br />RX-(Pharrn)_____ OnI. COlruP�ated BOY (4.32 Cufc,)
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ►
<br />described above by the proper shipping name, and are classified, packaged, marked and labellediplacarded, and
<br />are in all respects In proper condition for transport according to applicable International and national governmental regulations."
<br />2C. NO. OF 2D. VOLUME
<br />CONTAINERS
<br />Printed/Typed Name Signature Date
<br />4. TRANSPORTER 1 ADDRESS: Phone C (20M 2 4-7
<br />Z_�E] This is a Through Shiialtlenl Applicable Permlt Numbers:
<br />E0 7375 R A i3ridueford Rd. TSIO`_ T-20
<br />�°�, Siccklon, CA 95206
<br />E TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />~ PrinLr ype Name Signature Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone ll:
<br />i
<br />Applicable Permit Numbers;
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical Waste as described above.
<br />Print/Typs Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone q:
<br />Applicable Permit Numbers:
<br />s INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrInt/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />❑ 8A. Designated Facility: Lj 8B. Alternate Facility: 5C, Alternate Faculty: So. ANemale Facility:
<br />t StcfIGYGIe, Inc. (Autoclave) Staricy le, Inc. (incinerator) StericYole, Inc. (Autoclave) Covanta Marion, Inc.
<br />t �1 7675 RA Bridgeford Rd. 90 N. Foxboro Drive 2775 E. 26rh St, 4650 Brooklake Road NE
<br />Stockton, CA 952013 North Salt Lake, UT 84054 Vernon, CA 90053 crooks, OI? 97305
<br />(209)2944!14 (301)9313-1171 (6(30)733-7422 (505)393-0890
<br />TS/05T SO 3A1 ?-161JA-J0 Ft mrit r+ 30,1
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above Indicated wastes In accordance with the requirement outlined In that authorization.
<br />PrIntlType Name Signature Dale
<br />Cu
<br />
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