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e --- — ��`T-- -- — MEDICAL WASTE TRACKING FORM NUMBER <br />0.4 <br />• Ster'tycle° STANDARD MANIFEST 001 -10.06 -STD <br />s� s7 i. a. j► I E OF EMERGENCY CONTACT: CHEMTREG 1-800-424.9 <br />• vmtaengPWIO•seducino><Id: Route 0: 134 -- 10 CUSTOMER NO.2113 i' DFROOK4NJ <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />STOCKTON PERSONAL CARE CENTER <br />601 N CALIFORNIA ST <br />STOCKTON, CA 95202- 2118 <br />CusTOMERNuMeER 60381 <br />2A. DESCRIPTION OP WASTE 128. <br />UN3291, Regulated Medical Waste, n.o.s., <br />OM <br />(209) 466-8075 <br />GENERATOR'S REGISTRATION # <br />CONTAINERTYPE <br />T805 – 40 tial Tub (Bio) (5.3 cu ft) <br />T1349 – 31 Gal Tub (Dio) (4.9 Cu ft) <br />T914 - 4.4 Gal Tub (Bio) (5.9 Cu ft) <br />TB21–(BIo)/TP1S–(Path)/TY15-(Chemo)20 Gal Tub(2.7CUFT <br />WB31-(Bio)/WB31–(Bath)/WC31–(Chema)31 tial Tub(4.14 <br />WB43- (Bi.o) /pfr 63- (Fath) /CW43- (Chemo) Gal Tub (S.7CUPT) <br />KRB – Biosysteras Cardboard Box (4.2 cu ft) <br />2C. NO. OF <br />CONTAINERS <br />1/17/2018 <br />VOLUME <br />3. Gonoratoes Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS 1111� / Gu 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 />tt a— / <br />1 Printedlry ed Name 'jl'- ' �` SEgnature Date i w� ~ <br />4, TRANSPORTER 1 ADDRESS:® Phone #• (866) 763-7422 <br />Ster�.Cycle, Ina. This is a Through shipment Applicable Permit Numbers: <br />10. <br />4135 Q. Swift Ave Hauler Regi# 3400 <br />Freano,CA 93722 <br />a � TRANSPO C�TJFICA�TION:medical waste as described above. <br />Printliype Na e Nt Si nature – Date <br />5. INTERMEDIATE HANKiR 2 / TRANSPORTER 2 ADDRESS: Phone #: <br />SApplicable Permit Numbers: <br />10o <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Printnyps Name Signature Date <br />m 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #: <br />S Applicable Permit Numbers: <br />N a INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as descnbed above. <br />xd. x <br />!z Prinmpe Name Signature Date <br />7. DISCREPANCY INDICATION <br />f]ArDoullanatod Facility: U 813. Alternate Facility: ® 8C. Alternate Facility: ❑ 60. Ahemate Facility: <br />Stericycle, Inc. Steilcycle, Inc. Stericycle, Inc. <br />4135 W. S+NIftAV4 SON. Foxboro Drive 1561 Sheifion ©rive <br />u. resno CA 837 At1N>r 9a North Solt Lake, UT 84054 HolllEtter. CA 95023 <br />(866)713-7422a (866)783-7422. (866)783-7422 <br />TSIOST22 BA -448-.W36 TSfOST 83 <br />,! g JAN <br />TREATMENT FACILITY: I certt at I ve been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />F received the above Indicated ordance with the requirement outlined in that authorization. <br />Printllype Name <br />W <br />MY <br />„ ORIGINAL <br />Date <br />UN3291 Regulated Medical Waste, <br />6.2, pall <br />8N329111 Regulated Medical Waste, <br />CC ® <br />Regulated Medical Waste, <br />6.2, Kill <br />dUN3291 <br />,C <br />W <br />UN3291 Regulated Medica! Waste, <br />6.2, F011- <br />UN3229 -1 Regulated Medical Waste, <br />IZ, <br />OM <br />(209) 466-8075 <br />GENERATOR'S REGISTRATION # <br />CONTAINERTYPE <br />T805 – 40 tial Tub (Bio) (5.3 cu ft) <br />T1349 – 31 Gal Tub (Dio) (4.9 Cu ft) <br />T914 - 4.4 Gal Tub (Bio) (5.9 Cu ft) <br />TB21–(BIo)/TP1S–(Path)/TY15-(Chemo)20 Gal Tub(2.7CUFT <br />WB31-(Bio)/WB31–(Bath)/WC31–(Chema)31 tial Tub(4.14 <br />WB43- (Bi.o) /pfr 63- (Fath) /CW43- (Chemo) Gal Tub (S.7CUPT) <br />KRB – Biosysteras Cardboard Box (4.2 cu ft) <br />2C. NO. OF <br />CONTAINERS <br />1/17/2018 <br />VOLUME <br />3. Gonoratoes Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS 1111� / Gu 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 />tt a— / <br />1 Printedlry ed Name 'jl'- ' �` SEgnature Date i w� ~ <br />4, TRANSPORTER 1 ADDRESS:® Phone #• (866) 763-7422 <br />Ster�.Cycle, Ina. This is a Through shipment Applicable Permit Numbers: <br />10. <br />4135 Q. Swift Ave Hauler Regi# 3400 <br />Freano,CA 93722 <br />a � TRANSPO C�TJFICA�TION:medical waste as described above. <br />Printliype Na e Nt Si nature – Date <br />5. INTERMEDIATE HANKiR 2 / TRANSPORTER 2 ADDRESS: Phone #: <br />SApplicable Permit Numbers: <br />10o <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Printnyps Name Signature Date <br />m 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #: <br />S Applicable Permit Numbers: <br />N a INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as descnbed above. <br />xd. x <br />!z Prinmpe Name Signature Date <br />7. DISCREPANCY INDICATION <br />f]ArDoullanatod Facility: U 813. Alternate Facility: ® 8C. Alternate Facility: ❑ 60. Ahemate Facility: <br />Stericycle, Inc. Steilcycle, Inc. Stericycle, Inc. <br />4135 W. S+NIftAV4 SON. Foxboro Drive 1561 Sheifion ©rive <br />u. resno CA 837 At1N>r 9a North Solt Lake, UT 84054 HolllEtter. CA 95023 <br />(866)713-7422a (866)783-7422. (866)783-7422 <br />TSIOST22 BA -448-.W36 TSfOST 83 <br />,! g JAN <br />TREATMENT FACILITY: I certt at I ve been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />F received the above Indicated ordance with the requirement outlined in that authorization. <br />Printllype Name <br />W <br />MY <br />„ ORIGINAL <br />Date <br />