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MEDICAL WASTE TRACKING FORM NUMBER
<br />JWA
<br />SE OF E ERGENCY CONTACT: CHEMTREC 1-800.42 STANDARD MANIFEST 001.10.06 -STD
<br /># CUSTOMERNO.2 2 MDFROOKSBO r
<br />••.••a aeauaa ear,, �s� 6.10 D6 44f
<br />1. Generator's Name, Address and Telephone Number + j
<br />ATTN:Lavonne Baldwin
<br />.FNiE r,XN TIED CR0!;5--5T0CKT0'N
<br />t
<br />65 N COMM (M 5T
<br />STOCKTON, CA :0520;-- 2318
<br />(209) 644-5031.
<br />7/11/2018
<br />6146762-001
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2t3. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />T804 — 28 Gal Tub (Bio) (3.7 cu ft)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n,o.s.,
<br />T-1349 — 37 Gal Tub (Bio) (4.9 cu ft)
<br />6.2, PGII
<br />Cu Ft.
<br />M
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TID14 — 44 Gal Tub (Bio) (5. 9 cu ft)
<br />f7-7
<br />0
<br />6.2, PGII
<br />'3
<br />Cu Ft.
<br />Q
<br />UN3291, Regulated Medical Waste, n.o.s•,
<br />T ? Tl? Tx tan u
<br />6,2, PGII
<br />Cu Ft.
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />Z
<br />6.2, PGII
<br />Cu Ft
<br />UN3291, Regulated Medica] Waste, n.o,s.,
<br />G.2, PGII
<br />IIS_ ( ) � p43_ ( ) %WC43_ { ) iinl Tub (S. 7GurT)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Kk _ Biosystems Cardboard Box (4.3 cu ft)
<br />--
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGO
<br />Cu Ft
<br />3. Generator's Certification: "] hereby declare that the contents of this consignment are fully and accurately TOTALS®
<br />3 t 7 . Cu Ft.
<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 />1 �
<br />? yPrintedfryped Names ` Signature
<br />Date
<br />4. TRANSPORTER 1 A DRES :
<br />St erOyC e, Ina. ® This is a Throug ship it
<br />Phan ^ 14
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<br />>- I—
<br />4135 W. 5Wift: Ave
<br />Applicable Permit Numbers
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<br />Hauler Reg## 3400
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<br />Fresnc,CA 93722
<br />.�—
<br />IL ¢
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />X
<br />Print/Type Name -e. Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />aNr,4
<br />Applicable Permit Numbers
<br />D
<br />s
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />�r
<br />PnnVType Name Signature
<br />Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />o
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />h^
<br />PrintlType Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facility: E]8B. Alternate Facility: 8C. Alternate Facility: 8D.
<br />N
<br />t
<br />aMerlcycle, Inc.rI Cle, Inc. Sterlcvcle, Inc.
<br />4135 W. SWIttAVe
<br />Alternate Facility:
<br />Covanta Marlon,lnC
<br />U
<br />0 N.Foxboro Drive 1651 Shelton Olive
<br />4550 BrooMake Road NE
<br />Cts Via, 37
<br />s�3 t A3 -?422 2 orih Sats Lake, IIT 84054 Hollister, CA 95023
<br />Brooks, OR 97305
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<br />TGlOST 22 (6Q1)936-1171 (866)783-7422
<br />DALE ANNEOSM 8A-4481JA-28 TSIOST-83
<br />1605}393-0890
<br />Peltrtit#3ts4
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<br />TREATMENT FAAA41 cer TLI I have been 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 />PrInUType Name S-anature
<br />Date
<br />••.••a aeauaa ear,, �s� 6.10 D6 44f
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