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01/24/2019 14:21 FAX 00002/0010
<br /> .......... ............. ..........
<br /> SERVICE RECEIPT -AL WASTE TRACKING FORM NUMBER
<br /> �ANDARD MANIFEST 001-10-06-STD
<br /> .10-06-STD®
<br /> 0
<br /> ,r.1EMF.,9ENCY cppi #: 6017746-00?
<br /> Stericycid
<br /> 1.
<br /> Delta Sierra ai,ly,j,
<br /> Center
<br /> 1.Generator's Name,Address and Telephone Number SERVICE DATE: 12,!2411�\�*16-33 A
<br /> ATJNRetvner,1 Kaur DRIVER ID: Flores, Sal
<br /> D E LTA.-8 1 F R.f k A I)W�YS I S C EN TE 8 S81PPI116 DocunElIT 0:
<br /> 5,55 W BENJAMIN H(A-T EIR S;W 200
<br /> 06207-3830 TOTAL COLLECTED: 7
<br /> TOTAL VOLUME: 41,3DO Co FT
<br /> 0OA0711 T814 0OA0712 t814
<br /> 0OA0710 y814 0OA0713 7814
<br /> CUSTOMER NUMBER 6017703-002 0OA0710 T814 0OA071F T814 DOA0711I T914
<br /> 2A.DESCRIPTION OF WASTE 25. 2C, NO.OF 2D, VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., 11114- 28 Gat Tub(RW) S. CONTAINERS Cu Ft.
<br /> 6.2,PGII 50MARY(Cont Type) VOL
<br /> UN3291,Regulated Medical Waste,n.o.s., TB49-37 Gal Tub (Sic) (4. QTY CIF
<br /> 6.2,PGII T014 44 G31 Tub Df$P(8,o) 12, Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., Tkl,*,-44 Gail'ub(Rlo) (5J 7 41,300 Cu Ft.
<br /> 6.2,PGII
<br /> PO --
<br /> UN3291,Regulated Medical Waste,n.o.s., T821 4'....—Y1 DELIVERY DOCDOCUMENT-1 .—
<br /> FRO0,m Cu Ft.
<br /> 6.2,PGII
<br /> UN3291,Regulated Medical Waste,n.o.s.
<br /> 6,2,PGII Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII ti._....... Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., KR Biosyfiterrm Cardboard Box(4.3 cu ft)
<br /> 6.2.PGII Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII Cu Ft,
<br /> UN3291,Regulated Medical Waste,n
<br /> 6.2.PGII Cu Ft.
<br /> 3.Generator's 110-r's Certification:"I hereby declare that the contents of this consignment are fully and accurately I, Cu Ft.
<br /> des97jl),p,0 above by the proper shipping name,and are classified,packaged,marked and labelled/placa.rderl and
<br /> Agro in all re pects in proper condition for transport according to applicable international and national,governmental regulations!
<br /> XPrrit6dfTyped Name Anat6re t bate
<br /> 4.
<br /> 'TRANZ§PORTER1 DRESS- Phone#Ofy 44 2
<br /> Sipporicycki, Inc. i I iz is a f6i,otilgh Shipment Applicable Permit Numbers:
<br /> 4,135 V1, �W f 11 Alit
<br /> Fregno,CA g§34 0 0
<br /> TRANSPORTEP.)CZRTIFI A ION: Rece�pt Rf.medical waste as described�Iboye..
<br /> Printrl'ype Name Date
<br /> 77 , Signature
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone 0:
<br /> Applicable Permit Numbers:
<br /> t INTERMEDIATE ERIVIEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name —Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 4:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> 8A.Designated Facility: 813,Alternate Facility: 8C.Alternate Facility: E] 81),Alternate Facility:
<br /> -
<br /> yde,Inc.(Aub.-iciff.,de) Cownta Marlian,lr,:;
<br /> .41 K,Vv.Swift'AN.";p 90 N.Foxboro Drive Sh*.Ib'jn D?Ilvo, 4lik"60 BrorOMov Rtmrid NE
<br /> dawlki.wVAa,kJT C4,40111-11 V4\.1fl)wUjV,'tdlk alpoAo vfoovhes,#irk 07V00
<br /> 3/-'v-446fJA-3Pj TSWOST-83 Ple)rrilt zli34
<br /> 4
<br /> REATIMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> ceived the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type Name Si najure Date
<br />
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