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<br />IN CgSE UIQ F ET�IIERG CY CONTACT: CHEMTREC 1.800424.9300 STANDARD MANIFEST 001.03.21•NOCA
<br />tiCllt;' 's7: i CUSTOMER NO, 21132
<br />`TBE&TNIENT FACILITY:1 ceffify that I hav# been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received tli In acc rdance with the requirement outlined In that authorization,
<br />PrinMpe Name Signature Date
<br />1. Generator's Name, Address and Telephone Number
<br />n
<br />rl �t�,: f. wain FlaugIIIIIfill
<br />RXIMSGIAF CARE CENTER
<br />25113- E W+-IITMORE AVE
<br />12/29/2021
<br />CERES, CA 953 07-2.6,15 (209) 521-6097
<br />6131469-750
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION M
<br />2A.DESCRIPTi0NOFWASTE
<br />29• COONTAINERTYPE
<br />2C, NO. OF
<br />21). VOLUME
<br />Regulated Medical Waste, most
<br />,F'R7-(I�i i9i tri) :[ 'Ghelr V.1I eeled f:ack (412 C:Lifi)
<br />CONTAINERS
<br />6N3291Pr31I
<br />Cu
<br />UN3291 Regulated Medical Waste, n.o.sl'RR3-(fo118+1i1)'3
<br />Shell' heels'd Roc.: (52 t_ -'Lilt.)
<br />6.2, PGII
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<br />CC
<br />UN3291 Regulated Medical Waste, n.os.1
<br />: X .-(Ph-3rli))_,___„ GE0. Con-ugBted BOK (4.321 CU If. )
<br />0
<br />6.2, PGII
<br />Cu
<br />UN3291 RegulaledMedical Waste, n,o.s;,f
<br />6,2,
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<br />PGII
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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
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<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
<br />Cu
<br />UN3291 Regulated Medical Waste, n,o,s.,
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<br />UN3291 Regulated Medical Waste, n.o.s.,
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ►
<br />Cu
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are In all respects In proper condition for transport according to applicable International and national governmental regulations"
<br />Printed/Typed Name Signature
<br />Date `��'r+
<br />9-
<br />4. TRANNSPORTER i gqDDRESS:
<br />•_111loycle, filC. � TI11S is 0 -1-111'01-19h `11II?I110111
<br />Phonlr 0J J.3 L'J',-r 1 I'1
<br />x
<br />7875 F: A Di�lcteford Rd.
<br />Applicable P.ermRNumber
<br />I o -S 1-60
<br />re
<br />Stockloll, CA 55206
<br />L
<br />2
<br />TRANSPORTER C FICATION: Recel t of medical waste as described above.
<br />G"�CQrq
<br />I
<br />Print/Type Name Signature�
<br />Date
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone R:
<br />j
<br />Applicable Permit Numbers:
<br />f
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinUType Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS:
<br />Phone N:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />•
<br />PrinVType Name Signature
<br />Dale
<br />7. DISCREPANCY INDICATION
<br />8A, Dealgnat
<br />SB, emate Facllfty:
<br />❑ SC, Aftemate Facility:
<br />8D. Attemate Facility:
<br />j
<br />'f • /i•IE, InC•. (/1u1 + -''
<br />GALEA
<br />"sflC.jG1 ,Inc, (Incin_rator) St
<br />tfIGyGIB, Inc, (H,Ut!Cla\'e)
<br />r ,�lh f 13rICn, Inc.
<br />7 3 R A kiridgj' ?,�� r:.c . 9i
<br />H. Fo ,boin Drive 2 ;
<br />7v G. loth Wit,
<br />4" 51) BrooHake Road HE
<br />Ii
<br />th S,i tUT 81054 VE
<br />rr 08
<br />Co1's,I CI - 7?U5�Oz�
<br />t2^17119(b
<br />'c,
<br />OK`f (E)793-71?
<br />$�
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<br />`TBE&TNIENT FACILITY:1 ceffify that I hav# been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received tli In acc rdance with the requirement outlined In that authorization,
<br />PrinMpe Name Signature Date
<br />
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