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— — a————--—— —— MEDICAL WASTE TRACKING FORM NUMBER
<br /> a:ea Stericyc Ira IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800.424-9300 STANDARD MANIFEST DOt-10.06-STD
<br /> J ROUte #^- 124 - 22 CUSTOMER NO.21132 MDFROOMSG9
<br /> t.Generator's Name,Address and Telephone Number
<br /> J DTH QUAIL LAKE-CHATEAU HSATL
<br /> 1221 ROSEMARIE LN
<br /> STOCKTON,CA X207-6703
<br /> (los)477-28U 12/18><201'
<br /> i
<br /> CUSTOMER NUMBER 6156205-001 C.FXERATOR'S REGIMAMON#
<br /> 1 2A.DESCRIPTION OFWASTS, 2B. CONTAINERTYPE 2C. NO.OF 2D. VOLUME
<br /> UN3291,Regulated McTkal Waste,n o.s., CONTAINERS
<br /> 6.2.PGII T804-28 U TubBI+� 3.7 eu Q Cu F_
<br /> 6 2329!1 Regulated Medical Waste,n o.s_, TI# -37 Gat Tub(B(o}(4.g>�fl)
<br /> l Cu F.
<br /> i a: UN3291,Regulated Medical Waste n.D.s.,
<br /> i o 6.2,P611 1 -".Gal Tub(Bio)(5.9 cu ft)
<br /> UN3291Regulated Medical Waste,n.o.s., TB21-(„_,_,)frPI54__ . 1'5`�)2O Gal Tub�(2.7CUFT) Cu
<br /> i6.2,PGII Cu F:
<br /> W UN3291,Regulated Medical Waste,n-O.s.,
<br /> I Z 6.2,FGII Cu FUNS _
<br /> 6.4 PGsi 91 Regulated Meduat Waste,n e.s, Ve43-( __J/WP43-{, )/WC43-(_)Gal Tub(5.7CUFT) Cu
<br /> ! UN3291,Regulated Medical Waste,n o.s.,
<br /> I 6.2,Fell KR -Biosysterns Cardboard Box 4.3 cu ft) Cu
<br /> UN3291.Regulated Medical Waste,n.o.s.,
<br /> 6.2,Pall Cu F.
<br /> UN3291,Regulated Medical Waste,n.o.s., Cu F
<br /> 6.2,Pall
<br /> 3.Generator's Certhication;'I hereby declare that the contents GI this consignment are fully and accurately Tt?TALS 1=0" Cu
<br /> cle§sM§asove by the proper shipping name,and are classified,packaged,marked and labelled/placarda ,and
<br /> e in:al res acts in proper condition for trannsport accortim to applicable Intemattonal and nati mental regulations.'tedir � `�°`� SE natters r Dat©
<br /> NSPORTER 1 ADDRESS; Phone#:(3 7422 '
<br /> w .rrterioyde, Inc. 0 This Is a Through Shipment Applicable Permit Numbers:
<br /> a o 4135 W.S IIIc l Its Hauler Ree,#U60
<br /> Fresno,CA 83722
<br /> c¢.a TRANSPORTER CERTIf(CATION:Receipt of medical waste as doser ab
<br /> PrinUrype Name '� Signature Date _
<br /> 3.INTERMEDIATE HAND 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> Applicable Permit Numbers:
<br /> 12�a
<br /> = INTERMEDIATE HANDLER i TRANSPORTER CERTIFICATION:Receipt of medical waste as described_above.
<br /> Prinvfte Name Signature Date
<br /> Mw 6.INTERMEDIATE HANDLER 3/TRANSPORTER aADDRESS: Phone#:
<br /> Applicable Porrnit Numbers:
<br /> w
<br /> INTERMEDIATE HANDIER/TRANSPORTER CERTII=ICATION:Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> } SA.Designated FscRety: U SB,Alternate Facility: ❑8C.Alternate Facility: - ®SD.Alternate Facility:
<br /> J cycle,Inc.(Autocl") Stertcycle,Inc.(Incinerator) Stericycle,Inc.(AiAociave) Covants Marion,Inc
<br /> 415 ,SW2Ava 90 N.F6xb#rid DriVa 1561 Shelton Deft 4860 SrOOMaKe Road NE
<br /> LL Fresno,CA 93722 North Sant Lake,UT 84054 Hollister,CA 95023 Brooks,OR 97305
<br /> (888)783-7422 (80#)9361-1171 (8661783-7€22 (505)393"-0890
<br /> TWOST-22 3A-448/JA-36 TWOST 83 Permit#:364
<br /> DALE A14NE OR-TIZ
<br /> s TREATMENT FACILITY:l certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have
<br /> l- received the above Indicated wastes in accordance With the requirement outlined in that authorization.
<br /> Printft'ype Mme-' 3 2019Signature pale
<br /> Transferred containers, ou ft to :Brooks,OR
<br /> Transferred containers, CU ft to :N.Sak Lake,UT
<br /> ORIGINAL
<br />
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