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<br /> ® 1 ' ® SERVSTANDARD MANIFEST 001-70-06-STD
<br /> 1 `r ICE RECEIPT $800 4
<br /> JER
<br /> COUNT#: 615679-001 4 t, i T
<br /> 1.Generator's Name,Address andT�� � Delta Sierra Dialysis Center , 11
<br /> AT
<br /> TN'Rab
<br /> SERVICE DATE: 2/17,20i oras AM z i
<br /> SIERRA O$ y
<br /> DRIVER I0: Flores, Sal
<br /> 7500 WEST LN SHIPPING DOCUMENT#: MDFROONOTH
<br /> TOCKTON, CA 95210-
<br /> 31 TOTAL COLLECTED: 14
<br /> ry I TOTAL VOLUME: 82.600 CU FT
<br /> CUSTOMER NUMBER 9 f OOADDDI T914 0OA0002 T814 0OA0003 T814 IISTRATION#
<br /> 0000004 i814 0000005 T814 0000006 7814 2C. NO.OF 2D. VOLUME
<br /> 2A.DESCRIPTION OF WASTE 2B j 0OA0007 T814 OOA0008 T814CONTAINERS
<br /> 0000009 T814
<br /> 6.23291,Regulated Medical Waste,n.o.s., 0000010 T814 Cu Ft
<br /> 6.2,PGII OOA0011 T814 0OA0012 T814 6.23291,Regulated Medical Waste,n.o.s., 0OA0013 T014 OOAOO14 T814
<br /> 6.2,PGII Cu Ft
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<br /> Cr UN3291,Regulated Medical Waste,n.o.s., {` VOL t
<br /> Cu F
<br /> O 6.2,PGII SUMMARY(Cont Type)
<br /> QQTY CF 20 '1 131 �Tlf (2. t Cu F
<br /> 6.23291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII T814 44 Gal Tub Disp(Bio) 12. 14 82.600
<br /> W UN3291,Regulated Medical Waste,n.o.s.,
<br /> IZ 6.2,PGII DELIVERY DOCUMENT#: POFROONOTH v Cu F
<br /> UN3291 Regulated Medical Waste,n.o.s., da ,t3 ;5.1CUM Cu F
<br /> 6.2,PGII VIA
<br /> UN3291,Regulated Medical Waste,n.o.s., TOTAL DELIVERED ITEMS: 20 C i
<br /> 6.2,PGII KP Cu F
<br /> UN3291,Regulated Medical Waste,n.o.s., TYPE
<br /> 6.2,PGII QTY Cu F
<br /> UN3291,Regulated Medical Waste,n.o.s., T814 44 Gal Tub Disp(Bio) 12.7 lbs 20
<br /> 6.2,PGII Cu F
<br /> accurately TOTALS Do- t Cu F
<br /> 3.GeneCC,ator's Certification:"I hereby declare /placarded,and
<br /> described above by the proper shipping name,a DRIVER: Flores, Sal Tal governmental and
<br /> r ulatio s'f
<br /> p proper 1 p1 g g p ,
<br /> are in all r s ects in ro er condii'on for trans FREQUENCY: Every 4 Weeks
<br /> NEXT PICKUP: 2/26/2020 iature Date
<br /> 3dinted/Typed Name CUSTOMER SERVICE: Phone#: q3 $, �. 112�
<br /> 4.TRANSPORTER 1 ADDRESS Thank p
<br /> Sterit,'�`, Inc, You for choosing Stericycle "" Applicable Permit Numbers
<br /> d l�&tlit�'�"� ,.,a�iS�I� 'i"a pp
<br /> 4135 WIUljtt(ts° R<t 1g,P',!,4 0
<br /> (L Fresno,CA 9372'
<br /> a Z TRANSPORTER-CERTIFICATION: Rec
<br /> Print/Type Name Signature Date
<br /> 5,INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> a Applicable Permit Numbers:
<br /> wart
<br /> ¢Z5 LU J
<br /> 0LUz
<br /> Z W= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:;Receipt of medical waste as described above.
<br /> z
<br /> Print/Type Name Signature Date
<br /> M6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> w a¢ Applicable Permit Numbers:
<br /> S 5 W
<br /> 0.20
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Z s
<br /> c Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> �. 8A.Designated Facility: 8B.Alternate Facility: 8C Alternate Facility 8D Alternate Facility
<br /> JiPht,;Cly,illi;.(Autoclave) SUO`IdAx�i Incinerator)
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<br /> fJ -- 415>m S?0e,x'4W-' 90 N.
<br /> U. 9 V FrZ.Rno,w.K 9•.�6 Noft SEA Lakex
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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 />
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