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01/24/2019 14:21 FAX IM0003/0010
<br /> MEDICAL WASTE TRACKING FORM NUMBER
<br /> tericycle! STANDARD MANIFEST 001-10-06-STO
<br /> S
<br /> SERVICE RECEIPT
<br /> 1. Generator's Name,TI"Address and Telephone Number WACCOUNT#: 5017746-OOZ
<br /> ARavneet Kaur Delta Sierra Dialysis Center
<br /> DF-L"M SIERRA DI/M.N5111- GF-WER SERVICE DATE: 12/20/16\13:34 AN
<br /> 555 W BENAWIN HOUr DRIVER 10: Flores, Sal
<br /> 8T0('KT0N, (A 95207- 3339 SHIPPING DOCUMENT C IIOFROOLEOK
<br /> TOTAL COLLECTED: 10
<br /> CUSTOMER NUMBER 6011746-002 TOTAL VOLUME: 52,600 CLI FT
<br /> 2A.DESCRIPTION OF WASTE 2B. 0OA0716 KROF ODA07I7 KRIIF 0OA0718 KRIlf 2C. NO.OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste,n.o.s., T804 28 Garllub (13io 0OA0719 KRIF G0A07HY T014 O0AO7A2 T814 CONTAINERS
<br /> 6.2,PGII 0OA0714 T014 0OA0715 T614 0OA0718 T014 Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., 're4o 3,? (,7,al 1,111) (Bite ooAo7lC T814
<br /> 6.2.PGII ....... Cu Ft.
<br /> UN3291 Regulated Medical Waste,n.o.s., 'elf B 14, -.44 Gal Tub( 'a
<br /> 6.2.PGII VOL Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., �)n P i SUMMAKY(Cont Type QTY CF
<br /> 6.2,PGII Cu Ft,
<br /> UN3291 Regulated Medical Waste,n.o.s., KgIF Corr. Box Disp v/2-8931 4 17.200
<br /> 6.2.PGIi
<br /> UN3291,Regulated Medical Waste,n.o.s., T814 44 Got Tub Otsf)(810) 12- 6 35-400 Cu Ft.
<br /> 6.2,PGII Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., DELIVERY DOCUMENT #; POFROOlitOK --------
<br /> 6.2.PGII Cu FI.
<br /> UN3291 Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII n.o.s., TOTAL DELIVERED ITEMS: 7
<br /> Cu Ft.
<br /> UN3291,Regulated Medical Waste,mos..
<br /> 6.2,PGII
<br /> Cu Ft.
<br /> 3.Generator's Certification;"I hereby declare that the contents of this consignment are fully and accurately TOTALS ® Cu Ft.
<br /> described above by the proper shipping name,and are classified,packaged]marked and lalbelled/plaQarded,and
<br /> --1.1 a1 ' Ing to applicabie`Jniernationai and national govemetalgulations
<br /> r�%pre ."
<br /> aro ii [ respects In proper condition for transport accord
<br /> A
<br /> PrintedfTyped Name 4naf6re Date
<br /> Phone ,
<br /> _SS. ne N:(VU(J) 2 1U344.2
<br /> This Is a Through Shipmerd Applicable Permit
<br /> 4435 W, Swill Ate Numbers:F irem,(A 93722 HaU00der Rog#
<br /> TRANSPORTER CERTIFICATION: Receipt of medical waste as described abo a
<br /> PrInt(Type Name Signature, Date
<br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone 0:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATI
<br /> ...ON: Receipt of medical waste as described above.
<br /> PrinL(Type Name Signature, Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone
<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:
<br /> F]8B.Alternate Facility; EIC.Alternate Facility: E] ED.Alternate Facility:
<br /> j'$Uricycle,Inc. (Awt.0clave) �kericycip,Inc.(Incinerator) Stericycle,Inc,(Autoclave) ('o--iyama m(frion.Inc:
<br /> 4 1-'3C.W. Ave 9Ca f 1,Foxbor):z orivkv
<br /> (A 93?'22 Nofth Saft I-ake,LIT 8409.1 Hollister,CA 96023 '?r
<br /> (Otl i)q (866)783-7422
<br /> TSICIST-22 TWOST-83
<br /> TREATMENT FACILITY: I certify that 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 /> Print/Type Name Signature Date
<br /> 1.. ".
<br />
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