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01/{24/2019p�14:21 FAX Q0004/0010
<br /> ®® S I��OC��1.le® IN C�OF c�IMTRBC 1 90g 424.�,3Q STANDARD MANIFEST 001.10.00•STD
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<br /> 1. Generator's Name,Address and Telephone Null
<br /> T T�'�.C'ff�vnee1 KamSERVICE RECEIPT
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<br /> �l ..l_TA.y3 �4T lT?!�(LY�a�.► CENTERACCOUNt 6: 6017746. 02
<br /> ! i?i tPJ 1t1t.# ,7}'�lVithl TBt�T_'t"C)F? �i"N" ' 2t�fi Delta Sierra Dialysi center
<br /> eir (�fi N, � �1 �41- 3830 SERVICE DATE: 12/17115 42:35 AN
<br /> DRIVER 10: Flores, Sal
<br /> CUSTOMER NUMBER 60 '� !"'1"V""(.tt ,� $NIPPIIi6 DOCUMENT y: NDFR60lORt
<br /> 2A.DESCRIPTION OF WASTE 26• TOTAL COtIECTED'. 6 2C. NO.OF 2D. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., I TOTAL VOLUME: 33.500 CU f1 CONTAINERS
<br /> 6.2,PGII �l FJ04 -- :98 Gal'I""VIA I
<br /> UN3291,Regulated Medical Waste,mo.s., , Cu Ft.
<br /> 6.2,PGII '�k349- 37 Gal Tub OOA07NU KRSf OOA07NS T814 ODA071 TB14
<br /> 0OA079V 1614 OOA07NX T614 OOA0710 TBt4 Cu FI.
<br /> UN3291,Regulated Medical Waste,n.o.s., - �"^ r• ,
<br /> 6.2,PGII ?rB 14 -4�� (A al'Tula( VOL
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<br /> SUMM
<br /> UN3291P ,
<br /> GII Regulated Medical Waste,n.o.s., T821'T ( �{TTa 1 ARY(Cont Type) QTY CF r4"p�t
<br /> 6.2, Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII01 Dj5P v 2-Sgal 1 4.300
<br /> UN3291,Regulated Medical Waste,n.o.s., 1614 44KROF r6a r.®Tub D sp(Bio) 12. S 29.500 Cu Ft.
<br /> 6.2,PGII )7 i/Ik�T:ti-- qtr l�4n�, IJF I") Cu Fl.
<br /> 6.2,P611 Regulated Medical Waste,n.os•, KR /� 106}r tit OEIIVERY OOCUNEIIT Y: POFROOtORl
<br /> , Cu Fl.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII
<br /> T07A1 OE UVEREp ITEMS: 9 Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., QTY
<br /> 6.2,PGII TYPE Cu Fl.
<br /> 3. tha
<br /> e contents of thli
<br /> deGejlzRd above bytihe properlshipping byd acl e,andtahe class fled,pack KRSF Corr. Box Disp u12-Sgal Funnel 3 tAI_S ®
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<br /> ars in all aspects in proper conditlol for accPrdl aPPIlca T014 44 Gt Tub Oisp(Bio) 12.7 lbs
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<br /> Prl ted/Typed Name Dale
<br /> 4;TR9N PORTER 1 ADDRESS: Phone IT 5156),f��
<br /> 1 sterleyde, Itto. Applicable Permit Numbers:
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<br /> 4136 IM 'Sifl Ave DRIVER: Flores. Sal
<br /> Hauler Ro, 3-400rre:sno,t,A 03722 FREQUEIICY: Ueelly
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<br /> TRANSPORTER CERTIFICATION: Receipt of medical waste as de tIE)(T PICKUP: 12/20/15
<br /> f, ..,�c•- CUS70riER SERVICE
<br /> Print/Type Name l - - Signature, Thank you/or choosing Stericycle
<br /> Date i 1
<br /> 5.INTERMEDlATEWNDLE 2/TRA"SPORTER 2 ADDRESS: Phone q: r -
<br /> Applicable Permit Numbers:
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<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATIG as described above.
<br /> Print(Type Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone p:
<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 /> Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> ' fiA.Deafgneted Facility: 6B.Alternate Facility: ®BC.Alternate Facility: BD.Alternate Facility:
<br /> Yterl�cyt;Ie'InC:.E£��4_,c!14v:J� `Aetrleycle,Inc.(lncinevalor') eta i&,Inc.(e tG3oititne; e,�antca Marlon.ln::;
<br /> �•4l?b 1iV,F;vvii`CAve 90N Foxboro C3!'v* 1651 Sholtort D1'TwA X11360 r3r-i:�0kl2•Ik*Ri,i�(ri
<br /> t11'b Y72S 1,4c os N 1,'*%it UT
<br /> S40.64 Fiail.l> t CAMMI ar)G4a,L>S7; 1,
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<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 /> Transforrod.... .` ou ft to : "roe : 0A
<br /> Tfansforrod r.��IY1 leM i~ ,.� .�., .� (4 ft to :N.Gat'-:Lake, U7
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