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MEDICAL WASTE TRACKING FORM NUMBER
<br /> �•� Steric Clea IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800.424.9300 STANDARD MANIFEST 001-10.06•STD
<br /> Route #: 135 -- 19 CUSTOMER NO.21132 MDFROONfI XA
<br /> 1.Generator's Name,Address and Telephone Number IIIIIIIIIIIIIII tr E I ll�� Fl �I���� I`I � I III
<br /> ATTN:Grystal Moline I I N Ir I If I
<br /> VAN TRAM, DR RiCk DDS INC.
<br /> 1007 S MAIN ST
<br /> Iv1ANTECA, t;A 95337-5703
<br /> (209) 823-9218 10/212020
<br /> CUSTOMER NUMBER 6084572-001 GENERATOR'S REGISTRATION N
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINERTYPE 20. NO.OF 20. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., CONTAINERS
<br /> 6.2,PCN TB04-28 Gal Tub (Bio) (3.7 cu R) Cu Ft.
<br /> UN3291 Regulated Medical Waste,n.a.s.,
<br /> 6.2,PG I[ T849_37 Gal Tub ( )Bio 4.9 cu )
<br /> Cu Ft.
<br /> CC 6 2329111 Regulated Medical Waste,n.o.s., _44 Gal Tub(Bio) (5.9 cu Ry �
<br /> ` Cu Ft.
<br /> UN3291 Regulated Medical Waste,n.o.s., TB21-(�)1TP15-(__-__YFY154„_,_ j20 Gal Tub(2.7CUFT)
<br /> 6.2,PG11 Cu Ft.
<br /> LU UN3291,Regulated Medical Waste,n.o.s.,
<br /> +Z 6.2,PGI I Cu Ft.
<br /> 6.23291 PGII Regulated Medical Waste,n.o.s., WB434_)11AIP434--J WC43-(---)G@I Tub(5.7CUM Cu Ft.
<br /> 6 2, PGII Regulated Medical Waste,n.o.s., KR -Biosystems Cardboard Box(4.3 cu R)
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste,o.0.s.,
<br /> 6.2,PGII Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII
<br /> Cu Ft.
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accuratoly TOTALS + Cu 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 con iiton for transport acpmqlng to applicable International and national gov rumen I regul
<br /> Printed/Typed Nam, ks Signatur Data oh&'[y
<br /> 4.TRANSPORTER 1 ADDRESS: Phone N: ($0s)7 -742
<br /> LU Stericycie, Inc. ❑ This is a Through Shipment Applicable Permit Numbers:
<br /> iz 4135 W. Swift Arse Hauler Rem 3400
<br /> y Fresna,CA 93722
<br /> IL ¢ TRANSPORTER CE TIS �Flecl waste asdescri a
<br /> Print/Type Name tYSignature/( Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone N:
<br /> N
<br /> CC
<br /> Cr Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> �,A 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> CC S
<br /> Applicable Permit Numbers:
<br /> V
<br /> f S a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> 145
<br /> — Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> 8A,Designated Facility: ❑813.Alternate Facility: BC.Alternate Faclllty: BD.Alternate Facility:
<br /> M Sterlcycle,Inc.(Autoclave) Sterlcycle,Inc.(Incinerator) Sbericycle,Inc.(Autoclave) Covants Marlon,Inc
<br /> 4135 W.SWR AV* 90 N.Foxboro DN* 1561 Shelban Drive 4850 BrooWake Road NE
<br /> LL -� Pr"rm,CA 83722 NoM 4sIlk Lek*.IIT 94019+4 14o4Kaber,G 914023 Brooks,OR 97305
<br /> IM"7P4422plz (801)836-117.1 (866)783-7422 (30311393-0890
<br /> ZTSrIEVefl 3�44481.1A-36 TS/451=83 Permit#3fi4
<br /> FFOCT 0 2 2020
<br /> 1 TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F received I&Zg1gWdicated wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type Name Signature Date I
<br /> containers, cu R to Bmoks, OR
<br /> Transferred containers, cu R to : N.Sak Lake, LIT
<br /> i
<br /> ORIGINAL
<br />
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