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el" Stericycle' IN CAn(CoEIVFIGM CONTAffl: CHEMTREC 1-800-424-9300
<br />CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-10-05-STD
<br />MDF P.0 ON Z ZIr GENERATOR 1. Generator's Name, Address and Telephone Number
<br />ATTN:CCYStai Molina . III 1111 111111111 11 i i 1 11 111111111 111 ill 1111 IIII 111
<br />VAN IRAN, DR RICK DDS INC.
<br />1007 S MAIN ST
<br />MANTECA, CA 96337- 6703
<br />(209) 823-9218 10/23/2020
<br />CUSTOMER NUMBER 6084572-001 GENERATOR'S REGISTRATION #
<br />2A. DESCFIIPTION OE WASTE
<br />1JN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />28. CONTAINER TYPE
<br />TB04 -28 Gal Tub (Bio) (3.7 cu ft)
<br />2C. NO. OF
<br />CONTAINERS
<br />2D. VOLUME
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII TB49 -37 Gal Tub (Bio) (4.9 cu ft) Cu Ft
<br />UN3291, Regulated Medical Waste, n.0.5
<br />6.2, PGII TB14 - 44. Gal Tub(Bio) (5.9 cu ft)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s., TB21-( )ITP15-( )20 Gat I ub(i.7C.UF I) _)/TY15-(
<br />6.2, PGII Cu Ft
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII Cu Ft
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII W1343-( )/WP43-( )/WC43-(. ) Gal Tub(5.7CUFT) Ft Cu
<br />UN3291, 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, non.,
<br />6.2, PGII AA/Xi \ (j '5(9p-L- )fPf-4%.—rOck--AN/FIXIPE1 /2). ',2 G 1.,c__ Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII Cu Ft
<br />3. Generator's Certification:I he eby declare that the contents at this consignment are fully and accurately TOTALS 10. 3 c 0....._ 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 c ndilion for trrspor ording to applicable international and national governmental rogu
<br />X PrintecUTyped Name aVV:1-V tiO1/4....) Ok.. ICr'S Signature
<br />s
<br />../...--..,,...„ Date 1 0 PRIMARY TRANSPORTER 4. TRANSPORTER 1 ADDRESS: Phone : (866)783-7422
<br />Stericycle Inc. 0 This is a Through Shipment Applicable Permit Numbers:
<br />4135W. 4,vift Ave Hauler Reg# 3400
<br />Fresn
<br />-J•... TRANSPORTEL1000:0 IC • • • ....1110 edical waste as descr
<br />Print/Type Na SI 3 . Date SV. 4 111
<br />2
<br />wc c 1
<br />E
<br />—
<br />el
<br />Applicable
<br />5. INTE • .io 'ii •TE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone it:
<br />Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date TRANSPORTER 3/ INTERMEDIATE HANDLER 6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone 4:
<br />Applicabro Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical wasto as described above.
<br />Print/Type Name Signature Date U° TREATMENT FACILITY =.147""'"`""^r 7. DISCREPANCY INDICATION
<br />• BA. Designated Facility; 7(
<br />Stericycle, Inc. (Autoclave)
<br />4135 W, SWitt /Wel
<br />Fresno, CA 93722
<br />(886)783-7422
<br />TS/OT-22
<br />TREATMENT FA-CILITYTeeietify that
<br />received the atgOV4 ihdiaai68 wastes in
<br />Print/Type Nemec:111.-i 2 3 202.11
<br />I have
<br />accordance
<br />M. Alternate Facility;
<br />Stericycle, Inc. (Incinerator)
<br />90 N. Rotor%) Div.
<br />North Set Lake, UT 84054
<br />(801)936-1171
<br />3A-448/JA-36
<br />been authorized by the applicable
<br />with the requirement outlined
<br />Signature
<br />. 80, Alternate Facility:
<br />Stericycle, Inc. (Autoclave)
<br />1551 $hetton Drive
<br />Hollister, CA 95023
<br />(886)783-7422
<br />TS/OST-83
<br />state agency to accept untreated
<br />in that authorization.
<br />•
<br />medical
<br />Date
<br />8D. Alternate Facility;
<br />Covanta Marlon, Inc
<br />4850 Broollaic Road NE
<br />Brooks, OR 97305
<br />005)393-0890
<br />Permit* 364
<br />wastes and that I have
<br />—i Transferred containers, cu ft to : Brooks, OR C C 1.?.4 /1., /7.7. Transferred containers, Cu ft to : N. Salt Lake, UT ..7,1
<br />ORIGINAL
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