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MEbICAL(VASTIff TRACKIh1G Forml NUiVIDER
<br /> j®�s Stericycle! IN CAST:OF EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 STANDARD MANIFE$7401.10-06-S7D
<br /> e ✓ Route #., 1.24 — 1.3 CUSTOMER NO.21132 MDFROOMP L1 6
<br /> 1.Generator's Name,Address and Telephone Number 111111111111
<br /> M� 1111111111
<br /> ATTWasephine Yokingco !(
<br /> DTH QUAIL LAKE-CF@ATEAU HSPTL
<br /> 1221 ROSEMARIE LEE
<br /> STOCKTON,CA 98207-8703
<br /> (209)477-26U iif27l2019
<br /> i
<br /> ctrsTorBERNumsFR 6156205-001 GENERATOR'sREa1s7RAnoNilf
<br /> 2A.DESCRIPTION OF WASTE 2S. CONTAINERTYPE 2C. NO.OF 21D. VOLUME
<br /> CONTAINERS
<br /> 6.2 29i,Regulated Medical Waste,n.o.s., TB04_28 Gail Tub(Bio)(3J Cit ft)
<br /> Cu Ft.
<br /> UN3291i Regulated Medical Waste,n o.s., T942-37 Gal Tub(BIO)(4.9 CU ft) Cu Ft.
<br /> 6.2.PGI
<br /> O UN32911
<br /> Regulated Medical Udaste,n.o.s., Gat Tub(1316)(5.9 tit fl)
<br /> 6.2,FGII L Ff
<br /> 7Cu Ft.
<br /> Q UN3291,Regulated Medical Waste,no.s., -fB2f 15,�T�[154___�2Q Gal Tub(2. CU )
<br /> a: 6.2,P811 Cu Ft.
<br /> UJ UN3291 Regulated Medieal Waste,n.a.s.,
<br /> Z PGII Cu Ft.
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<br /> 62,FGIl Regulated Medical Waste,n.tzs, 3-(_,__)fYUA43 WC43-(_,_,}GalTub('5.7Cli� Cu Ft.
<br /> UN3291 Regulated Medical Waste,n.o.s,
<br /> 6.2,P(311KR,,.,._,-Biosystems Cardboard Box(4.3 cuff) Cu Ft,
<br /> UN3291,Regulated Medical Waste,n.os.. Cu Ft.
<br /> 6.2,PGII
<br /> 03291,Regulated Medical Waste,a.o.s.. Cu Ft. i
<br /> 6.2,PGII
<br /> 3.Generator's Certification:"t hereby declare that the contents of this consignment are idly and accurately TOTALS ► a Cu Ft. i
<br /> dBove by the proper shipping name,and are classified,packaged,marked and labeltedlplacarded,and
<br /> f+9 in 291 peels in proper condition for transport according to ap
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<br /> able Internatlollat and nation nrr�ntal egulations'
<br /> Pd to ed Name Y' !% l SI malar f+[,// 'Date
<br /> 4.7RA PORTER 4 ADDRESS: Phone ff ($ 3.7422
<br /> tu' Steri ,Inc. Q This Is rG qh pment Applicable Permit Numbers:
<br /> it Cr 4.138 W.S A Ave Hauler Reg#3400
<br /> °ova Fresno,CA,03722
<br /> a Q TRANSPORTER CERTIFICATION:Receipt of medical waste as desed bo f�
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<br /> Printflype Nemo=29L ffW6 Sign aill re Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> W Applicable Permit Numbers:
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<br /> INTERMEDIATE HANDLER ITRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Pran1/rype Name Signature Date
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<br /> S.INTERMEDIATE HANDLER 317RANSPORTER 3 ADDRESS: Phone#:
<br /> I @ Q a Applicable PerrnH Numbers:
<br /> Es 2 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
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<br /> Prinitrype Name Signature Data
<br /> 7.DISCREPANCY INDICATION
<br /> y =s 8A.Deatgnated Facility: 88.Alternate Facility; ®8C.A tomete Facility: 8D.Aftemata Facility
<br /> N R
<br /> cycle,Inc.(Autoctisve) Steri�cie,Inc.(incinerator) Sbericycle,Inc.(Autoclave) Coverrta Nation.Inc
<br /> cs 4136 W.$ attt Aw 90 N.FCXbt7rti Drive 1581 sheltort Gil" 4850 E3rr4OMO Road NE
<br /> F rim ta, 4A 112722 d Sdh SIR I".
<br /> .LST t34GS4 (866)783-7422
<br /> F{otAntior,CA SM25
<br /> Brooks, 0 990 ik5
<br /> 1- (8t6)T8344e2
<br /> z-§7' T'SIOST 22 3A-448/JAr36 TS/OST-83 Pefmlt#364
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<br /> W x.a TREATMENT FACILITY:I certify that i have been authorized by the appIicabie slate agency to accept untreated medical wastes and that i have
<br /> i I r received tt0 �d26%wastes in accordance With the requirement outlined in that authorization.
<br /> Printrrype Name Signature Date
<br /> rans rre costa ners, cu R to :Brooks,OR
<br /> Transferred contalnem, Cit R to :N.Sak Lake,UT
<br /> ORIGINAL.
<br />
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