|
• :• mericycle
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 14800.424.9300 STANDARD MANIFEST 001-03-21•NOCA
<br />Route #. 705 -13 CUSTOMER NO. 21132 MDTK0006CL
<br />1. Generator's Name, Address and Telephone Number Incinerate or Shred OnlY
<br />ATTN: Maria lff II##IIIII(IIII(II l it III II#(f#(fl(I#ff 1 it i#fli I #I(
<br />GMF ST4CKTON MEDICAL. PLANA 1
<br />2505 W HAMMER LN 12/2/2021
<br />STOCKTON, CA 95209-2839 (209) 422-7578
<br />6131468-001
<br />CusTowta Nuveen GUNRATnn-s REONTRAT10N •
<br />2A. DESCRIPTION OF WASTE
<br />28• CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN32DI Regulated Medical Waste.n,o.s.,
<br />T[314-(Bio)Z___TP14-(Path) TY14-(Incinerate) 44 Gal, Tub
<br />LI s
<br />�`� `l
<br />•
<br />: M: 2 94-711
<br />4. TRANSPORTER 1 AD3(gleford
<br />StedcyC1e� This is a Througt ItTtnel11 Apple rmitNumbers:
<br />Cul
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGIi
<br />TB21- 9io TP15- Path TY15- Chzrrio 20 Gal. Tub '
<br />( } ( )--- ( } (
<br />,7 Cuff. )
<br />Cu I
<br />UN3291 Regulated Medical Waste,n.o.s.,6.2, PGII
<br />7B49- Bio TY49- Chemo 7149 Incinerate 37 Gal. TL
<br />b 4.0 Cuft.'
<br />Cul
<br />62,PG1i1Regulated Medical Waste, n,os„
<br />W243-(Bio)_._,_,CNA43-(Chemo)1NAS-(Phanri) 43' Gal, TL
<br />b (5.7Cufttl
<br />• Cul
<br />UN3291 Regulated Medical Waste, n,o.s„
<br />6.2. PGII
<br />KR Bio Gal. Corrugated Box d.32 Cult.
<br />( ) i - ( )
<br />Print/Type Name Signature Date
<br />c„ i
<br />6.2, PG
<br />n
<br />Regulated Medical Waste, n
<br />Regulated Medical Waste, n
<br />7. DISCREPANCY INDICATION
<br />6, LDasipna4ad Fadi
<br />�t recycle, Inc, (A�W.,
<br />' 1 78 r6 FSA BridB� COz�
<br />5t• ckton, CA 9 v
<br />90 N.
<br />North
<br />r
<br />ab Fadllty:
<br />Inc, (Incinerator)
<br />choro DriYe
<br />It Lake, UT 84054
<br />] 8C. Atternah FWIKy:
<br />4terieycle,Inc, (Autoclave)
<br />2775 E. 26th St,
<br />Veroon, CA 90058
<br />LI W. Aftnu to Faculty:
<br />Covanta Marion, Inc
<br />4650 Brooklake Road NE
<br />Brooks, C- 97306
<br />i (2 9)294 7114 (801) -1111 (68G)78,.;-7422 (50x)393-U0!1U
<br />T OST80 � � '3A-446 JA -313 I I Pernvt # 364
<br />PitTR n 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 />PrinMpe Name Signature Date
<br />3. G*rwoor's Certlflaetlon: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS ► I jq 12 3 ,q Cu I
<br />described above by the proper shippjpg name, and are dassifled ckaged marked and labelled/placarded, snd
<br />are in all respects In proper oo It for transport according ppilcable International and national govemmental let lone"
<br />f r
<br />fWrr» n •.
<br />: M: 2 94-711
<br />4. TRANSPORTER 1 AD3(gleford
<br />StedcyC1e� This is a Througt ItTtnel11 Apple rmitNumbers:
<br />7875 R A Rd. T`fOST 80
<br />Stockton, CA 95206
<br />TRANSPORTER C RTIFICA ON: Receipt of medical waste as dear
<br />7k�/��%
<br />a] Wiwi
<br />PrinRpeName �� lam SlgnaturoData
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS; Phone N:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above,
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />6, LDasipna4ad Fadi
<br />�t recycle, Inc, (A�W.,
<br />' 1 78 r6 FSA BridB� COz�
<br />5t• ckton, CA 9 v
<br />90 N.
<br />North
<br />r
<br />ab Fadllty:
<br />Inc, (Incinerator)
<br />choro DriYe
<br />It Lake, UT 84054
<br />] 8C. Atternah FWIKy:
<br />4terieycle,Inc, (Autoclave)
<br />2775 E. 26th St,
<br />Veroon, CA 90058
<br />LI W. Aftnu to Faculty:
<br />Covanta Marion, Inc
<br />4650 Brooklake Road NE
<br />Brooks, C- 97306
<br />i (2 9)294 7114 (801) -1111 (68G)78,.;-7422 (50x)393-U0!1U
<br />T OST80 � � '3A-446 JA -313 I I Pernvt # 364
<br />PitTR n 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 />PrinMpe Name Signature Date
<br />
|