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01/24/2019 14:21 FAX Q0005/0010
<br /> MEUIUAL WAS I t I HAUKIINU t-UYMev,NUIVIDcn
<br /> ® -4 -
<br /> STANDARD
<br /> }MANIFEST
<br /> ANIFEST)001-10-06-STD
<br /> ® ®i® Stericyd'® 0. 1il N27
<br /> ............ TEAR HERE
<br /> 1. Generator's fame,Address andTelephoi SERVICE RECEIPT
<br /> A1. TI1.�CL1VflPt(- r s our ACCOURT R: 6017746.00
<br /> 1-1F-1-7ASIE:RRADA YSIt"y CE-MI Delta Sierra Dialysis Center
<br /> 551 5 X14 I'3UNJAAi114 II(Al DR I1-". SERVICE DATE: 12!13/18 8:00:47 AM
<br /> STOCK 1 ON, ('A 96201- U3 30 DRIVER ID: Parra, Rene
<br /> SHIPPIiJ6 OOCUMENT ti: M0FROOt0E6
<br /> CUSTOMER NUMBER 60 E J 4(, -,002 TOTAL COLLECTED: 7 nON#
<br /> 2A.DESCRIPTION OF WASTE 2B. TOTAL VOLUME: 38.100 CU FT 20. NO.OF 2D. VOLUME
<br /> CONTAINERS
<br /> UN3291,Regulated Medical Waste,n.o.s., ,
<br /> 6.2,PGII OOA07HP KRBf 0OA07HQ KR8F 0OA07HD TBtd Cu F
<br /> UN3291,Regulated Medical Waste,n.o.s., �•�� ^, •? 0OA07HG T814 0OA07Hl T914 0OA07HR i814
<br /> 6.2.PGII 0OA07HU T014 Cu F
<br /> X UN3291,Regulated Medical Waste,n.o.s., I 1 Cu F
<br /> 6.2,PGII VOL
<br /> QUN3291 Regulated Medical Waste,n.o.s., 621„� SUMHARY(Cont Type) QTY CF 'ttb(2,70AJF T)
<br /> 6.2,PGII Cu F
<br /> W UN3291,Regulated Medical Waste,n.o.s.,
<br /> Z 6.2,PGII KRSF Corr. Boz Disp v/2-8901 2 8.600 Cu F
<br /> W UN3291 Regulated Medical Waste,n.o.s., TB14 44 Gal Tub Disp(Bio) 12. 5 29.500
<br /> 6.2,PGII � � ( 1-015.If C ILIF-T) Cu F
<br /> UN3291,Regulated Medical Waste,n.o.s., DELIVERY DOCUMENT 0; POFKOOt0E6
<br /> 6.2,PGII (4 � "+Z R14 �,�. >� - Cu F
<br /> UN3291,Regulated Medical Waste,n.o.S., TOTAL OEIIVFREO ITEMS: 7
<br /> 6.2,PGII Cu F
<br /> UN3291,Regulated Medical Waste,n.o.s., QTY
<br /> 6.2,PGII TYPE Cu F
<br /> 7
<br /> 3.Generator's Certification:"I hereby declare that the TOTALS ® 1 '>• s Cu F
<br /> described above by the proper shipping name,and are< KRSF Corr. Boz Dtsp 1012 Bgal Funnel 2 rand
<br /> are in all respects in proper condition for transport accort, TB14 44 Gal Tub Oisp(810 12.7 lbs 5 *tai regulations:'
<br /> � f
<br /> Printed/Typed Name �'�1�1� �'� ' Date {
<br /> 4,TRANSPORTER 1 ADDRESS: hone 4:00,001783-4422
<br /> w stI(er1(. do, frie'. ...,N xa�ee r41fJOU .11 "n4li ive"NI
<br /> � _.�,,,, _ � 1 t Appllcabie Permit Numbers:
<br /> IL F resna.,(A
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<br /> Q TRANSPORTER CERTIFICATION: Receipt of medical wasto as described above. -
<br /> {
<br /> Print/TypeName ` ' ' '2 - Signature Date —
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS; Phone YI:
<br /> Applicable Permit Numbers:
<br /> �U w
<br /> w0
<br /> 0
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> w 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 0:
<br /> a Applicable Permit Numbers:
<br /> 25
<br /> a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> �z
<br /> Print/Type Name Signature _Date
<br /> 7.DISCREPANCY INDICATION
<br /> " 8A.Designated Facility: ❑8B.Alternate Facility: ❑8C.Alternate Facility: BD.Alternate FacBlty:
<br /> ,
<br /> �5}laricy�.le,Irl v.(oa,ll:ar:11145) Sterlcy/c lel,Inc,(incinerator) ;t,lertcyde,Inc (ALJtQr_t(V0) inc;
<br /> �10 N. FOX130170 riV* 1661 Sheftn De(`,T
<br /> F va are•:t e'�•t Ehs`12;Y t-,k rtt t 5Je9l;Lwk4.tJ('M654 b offistxxr,C ,' FsC t:j 1"31 oi:,1 J CJ'r'.:2
<br /> ; $
<br /> ($QA),K)e�-1171 (+3 )76 -7 i' i'iCl'."s) ti;,4� CI•�?dl;
<br /> 3A-14 WA-3185 "TWIST 821 f jc'rn r:k,C21.iat
<br /> i ..d
<br /> LH TREATMENT FACILITY: I certify that) have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> e received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type Name Signature Date
<br /> cantainaM,_.,..,_..
<br /> ou A to :N.GAR t_ako, UT
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