Laserfiche WebLink
cc <br />Lu <br />Z <br />LU <br />(5 <br />-0-- <br />MED{CAL WASTE TRACKING FORM NUMBER <br />Ste 11 yde- IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424.9300 STANDARD MANIFEST 001 -10 -DS -STD <br />° PralwIngra"pa .,e dngAlsk: Route 0: 334 — 10 CUSTOMER NO. 21132 MDF'ROOHGIU <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />STOCKTON PERSONAL CARE CENTER <br />604 N CALIFORNIA ST <br />STOCKTON, CA 95202— 2118 <br />CUSTOMERNuMaER 603817.2-002 <br />(209) 466-8075 <br />GENERATOR'S REGISTRATION # <br />2/3/2016 <br />2A. DESCRIPTION OFWASTE <br />28. CONTAINERTYPE 20. NO. OF <br />2D. VOLUME <br />U143291 Regulated Medical Waste, n o s., <br />6.2, PGIJ <br />TBOS - 4th Gal Tub (Bio} (5.3 cu ft) CONTAINERS <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n o.s., <br />62, PGI1 <br />TB49 - 37 Gal Tub (Bio) (4.9 Cu tt) <br />Cu Ft <br />UN3291 Regulated Medical Waste, n.o s„ <br />TB14- 44 Gal Tab (Bio) (5.9 Cu ft) <br />6.2, PGi) <br />Cu FL <br />2, 291PG(Regulated Medical Waste, n o.s., <br />TB21- (HTO)TP15- (Path) TY3.5- (Chemo) 20 Gaal Ttab (2.7Cu ) <br />6 <br />Cu Ft <br />6.2. �JJ Regulated Medical Waste, n.o.s., <br />Y3H31_ (Bio) /WP31— (Fath) /WC31— (Chemo) 31 Gal Tub (4.14C T) <br />Cu FL <br />6 23PGIj Regulated Medical Waste, n o s , <br />WB43-(B i.o) /PW43- (Path)/CU43- (Chemo) tial Tub (5.7CUFT) <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s, <br />MB- Biasystems Cardboard Box (4.2 au ft) <br />6,2, Poll <br />Cu Ft <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, Poll <br />Cu Ft <br />Cu Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately <br />-Innn_!L�J ..L _.._ L.• IL. �.�_�. —t__,__ ---- __J _-- –I --- —J _..1,__.J -- ._J I..L..n.-Jf.-1----J-.-i <br />T®TALS ® <br />Cu Ft. <br />are ill all respects In proper condition for transport according to applicable International and national governmental regulations" <br />cc 4. TRANSPORTER I ADDRESS• { <br />Ul Stericycle, Inc. <br />a a 4135 A. Swift Ave <br />a. FreanO,CA 93722 <br />a Q TRANSPORTER CERTIFICATION: Receipt of n <br />N Z t, \A,1t,12.\`2 ^'IN <br />Q This is a Through shipment <br />as described above. <br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Nww <br />h+�y <br />Egg <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />Data L -=-^-(- <br />Phone#: (866)783-7422 <br />Applicable Permit Numbers: <br />Bauler Reg# 3400 <br />Date / �— <br />Phone #. <br />Applicable Permit Numbers: <br />Date <br />M w 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone If: <br />fillApplicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />x <br />fE <br />— PrlpViype Name Signature Date <br />r� <br />I <br />L -j <br />7. <br />Doslgnatod FacifI�tty: <br />4Ve35cyyccfeSc c end <br />Frranaa,a:A 02722 <br />(886)783-742 <br />TS, 03T22 .�° <br />Be, Altemale Facility: <br />Stericycte, Inc. <br />90 N. Fo)d3oro Drive <br />North Suit Lek*, UT 84094 <br />(866)783-7422 <br />3A -4484A-36 <br />8C. Altemate Fac}laty: <br />Steilcycle. Inc. <br />1,551 Shebn Drive <br />Holtieter, CA 96023 <br />(866)788.7422 <br />TS/OST 83 <br />so. Altemato Facility: <br />Stertcycle. Inc. <br />3140 N 7th StreettTly <br />Kenaae City, KS 66116 <br />(866)783-7422 <br />T3/OST 26 <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 />Name <br />Signature <br />Date <br />