|
•. Stericycle
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-424.930D 57ANDARD MANIFEST 001.0341-NOCA
<br />Route #t 705 -12 CUSTOMER NO, 21132 MDT K000853
<br />III s Il I-at�prury mat l rtave been autnorizea by the applicable state agency to accept untreated medical wastes and that I have
<br />received de n cated wastes In cordance with the requirement outlined In that authorization.
<br />Slgnalurs Date
<br />1. Generator's Name, Address and Telephone Number
<br />/SGM D
<br />ff II !! +I ! I I
<br />WISGMDIBeughln�ln
<br />RXF MEDICAL PLAZA �
<br />2500 W I -JAMMER LN 12/23/20211
<br />STOCKTON, CA 95209-2839 (209) 521-6097
<br />6131468-750
<br />CUSTOMER NUMBER GENERATOR'S REOI67RATION N
<br />2A, DESCRIPTION OF WASTR
<br />2e. CONTAINERTYPE
<br />2c, No. OF
<br />2D, VOLUME
<br />UN3291 Regulated MedicalWasle, n,o,s.,
<br />((48 Rk (48) CLIft.
<br />ON2- Nltann 2 Shelf WhcoRad
<br />CONTAINERS
<br />6.2, PGII
<br />Cu
<br />623 PGII Regulated Medical Waste, n.o.s.,
<br />KR Shoff 0111colod Rack (52 Cult.)
<br />Cu
<br />CC
<br />623 PGII Regulated Medical Waste, n,o,s„
<br />ttx - Pit arm) Gal. Coaugatod C3ax (4.32 00.)
<br />O
<br />p
<br />. Cu
<br />823 291 PGII Regulated MedlcalWaste, n.o,s„
<br />PX_(Et_-(f tuft') G;ai.Ourrugatad Box (4.32 GO.)
<br />CC
<br />Cu
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s.,^
<br />6.2, PGII
<br />`
<br />Cu
<br />tZ
<br />VI
<br />UN3291 Regulated Medical Waste, n.0,s.,
<br />6.2, PGII
<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 />Cu
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />6.2, PGII
<br />Cu
<br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accurately TOTALS 1110- . Cu
<br />described above by the proper sh.Vping name, and are class ed, packaged, marked and labelled/placarded, and
<br />are in all respects in pro�conIon I If port acco dl o applicable International and national governmental regulations"
<br />AlIb
<br />6�"_Printed/Typed
<br />�
<br />12,Js3
<br />Na Signature Date
<br />CC
<br />tuc
<br />4.TRANSPORTER 1 ADDRESS: Phone 11: (2 9) 294-7114
<br />stcricyclf" Ina, This N 0 Thl'oUgh Shipment Applicable Permit Numbers:
<br />c
<br />1875 R A Bridcgeford Rd. TWOST--80
<br />N
<br />Stockton, CA 95206
<br />L Z
<br />TRANSPORTER CERTIF CATION: Receipt gldlcal waste as described above,
<br />J
<br />if
<br />PrinUType Name Signatur Date r
<br />6. INTERMEDIATE HANDLER eTRANSPORTER 2 ADDRESS: Phone N:
<br />f
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />PrinUType Name Signature Date
<br />6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M:
<br />Applicable Permit Numbers:
<br />2
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />x
<br />—
<br />Pdnt%pe Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />nA �tFlac�Il:01n
<br />Fatuity:
<br />SC. Alternate Facility;
<br />8D, Alternate Facility;
<br />-
<br />�g
<br />c. (Incinerator)
<br />Stertcycle, Inc. (Autoclave)
<br />Covanta Marlon, Inc
<br />c
<br />7A76 R t r� Rd,
<br />���
<br />0 N, FoXIx)rtN Ddy'?
<br />M6 R, 2 Qh St,
<br />5060 E3r,,�,idtilary. flnntf NF
<br />Stockton, t' 9�' 013
<br />forth Salt Lake, UTS(1056
<br />Vernon, CA 90068
<br />Broofts, OR 97306
<br />P
<br />(866)763-7422
<br />(605)393-0890
<br />S
<br />TS/OST-50
<br />-1,16MA-313
<br />l
<br />Pertri'dt Y1 36:1
<br />III s Il I-at�prury mat l rtave been autnorizea by the applicable state agency to accept untreated medical wastes and that I have
<br />received de n cated wastes In cordance with the requirement outlined In that authorization.
<br />Slgnalurs Date
<br />
|