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Stericycle' IN CASE OF E Route MERCIENCY CONT1T: CHEMTREC 'I-BOO-424-9300
<br />CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-10-06-STD
<br />MDFRO 003YM GENERATOR 1. Generator's Name, Address and Telephone Number
<br />ATTN:Crystal Molina
<br />VAN TRAN, DR RICK DOS INC.
<br />1007 S MAIN ST
<br />MANTECA, CA 95337- 5703
<br />(209) 823-9218
<br />111111111111111111111111111111111111111111111111
<br />11/20/2020
<br />CUSTOMER NUMBER 6084572-001 GENERATOR'S REGISTRATION #
<br />24. DESCRIPTION OF WASTE
<br />UN3291, Regulated Medical Waste, ne.s.,
<br />6.2, PGII
<br />28. CONTAINER TYPE
<br />TB04 - 28 Gal Tub (Bio) (3.7 au ft)
<br />20. NO. OF
<br />CONTAINERS
<br />2D. VOLUME
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />'TB40 -37 Gal Tub (Blo) (4.0 cu ft)
<br />Cu Ft.
<br />UN329I, Regulated Medical Waste, n.e.s.,
<br />6.2, PGII TB -44 Gal Tub(Blo) (5.9 cu ft)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, 11.0.5., TB21-(1,_)/715-( YTY 154 )20 Qat Tub(2, /QUI- I }
<br />6.2, PGII 2 Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s., WB43-( )/WP43-(_ ) Gal Tub(5.7CUFT) .)/WC43-( 6.2, PO Cu Ft.
<br />1JN3291, Regulated Medical Waste, n.o.s.
<br />6.2, PGII KR - Biosystems Cardboard Box (4.3 cu ft) ....-..— Cu Ft.
<br />UN3291, Regulated Medical Waste, n.0.$
<br />6.2, PGII Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s
<br />6.2, PGII Cu Ft.
<br />3. Generator's Certification: 1 he eby declare that the contents of this consignment are fully and accurately TOTALS ....2 - 7 Cu Ft,
<br />described above by the proper shipping name, and are classified, packaged,
<br />are In all respects In proper Condition for transport according to appli5ble
<br />X Printed/Typed Name _ ' llh"\YW I\\b5 Signature
<br />marked and labelled/placarded, and
<br />international and national government- egulations." .
<br />kiA
<br />.
<br />d Date t PRIMARY TRANSPORTER TRANSPORTER 1 A0II219ES:
<br />blencycie, Inc.
<br />4135 W. Swift •
<br />Fresno • 937
<br />TRANSPORT a t • . f edical waste as described
<br />•
<br />ab.
<br />Phone #: (etiti)/33- 421
<br />This is a T .ugh Shi Applicable Permit Numbers:
<br />Hauler - egAt 3400
<br />..•
<br />4011116°'. -C Print/Type Name --II% Signature Data a0
<br />i 1
<br />INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #:
<br />Applicable Per it Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />
<br />Dato TRANSPORTER 3/ INTERMEDIATE HANDLER INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date 54 TREATMENT FACILITY DISCREPANCY INDICATION
<br />.
<br />TREATMENT
<br />received
<br />Print/Typo
<br />BA. Designated Facility:
<br />, Stericycle, Inc. (Autoclave)
<br />4135 W. WM Ay*
<br />Fliirsilis, OA 52722i
<br />(111515)761-7422
<br />TS/03T-22
<br />DALE ANNE ORTIZ
<br />riAdR_TOYNertify that
<br />the abg\ e indicatejwastes In
<br />Namel
<br />lUV 20 ZU2U
<br />---TMEtenii—
<br />0 BB. Alternate Facility:
<br />Stericycle, Inc. (Incinerator)
<br />90 N. Foxboro Drive
<br />islortil Daik Lalry, UT 0,40114
<br />(O1)136-1171
<br />3A-448/JA-35 -
<br />I have been authorized by the applicable
<br />accordance with the requirement outlined
<br />Signature
<br />III BC. Alternate Facility:
<br />SterIcycle, Inc. (Autoclave)
<br />1551 Shelton Drive
<br />142111/2122i, OA 8.02,
<br />(55)7133-7422
<br />'TS/OST-83
<br />state agency to accept untreated
<br />In that authorization.
<br />In
<br />medical
<br /> Dato
<br />
<br />80. Alternate Facility:
<br />Covanta Marlon, Inc
<br />485013rooklaks Road NE
<br />Do:RA/2, OR a72041
<br />(505)393-0890
<br />Permtt # 364
<br />wastes and that I have
<br />tOrtie Mara GU •Rrooks, ,--1
<br />Transferred containers, cu ft to : N. Sak Lake, UT
<br />ORIGINAL
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