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Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-80G-424-9300
<br />Route #: 136 - 18 CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-1O06-STD
<br />MD F RO ON WXA GENERATOR 1. Generator's Name, Address and Telephone Number
<br />ATTN:Crystal Molina III VAN IRAN, DR RICK DDS INC_
<br />1007 S MAIN ST
<br />M4NTECA, CA 95337- 5703
<br />(209) 823-9218
<br />11111111111111111111111111111111111111111
<br />10/2/2020
<br />.
<br />111
<br />.
<br />CUSTOMER NUMBER 6084572-001 GENERATOR'S REGISTRATION/I
<br />2A. DESCRIPTION OF WASTE
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />5.2, PGII
<br />2B. CONTAINER TYPE
<br />TIF104 - 28 Gal Tub (Rio) (3.7 cu ft)
<br />2C. NO. OF
<br />CONTAINERS
<br />20. VOLUME
<br />Cu Fl.
<br />UN3291 Regulated Medical Waste, n.o.s.
<br />6.2, PGII T849 - 37 Gal Tub (Rio) (4.9 cu ft) Cu Ft.
<br />UN3291 Regulated Medical Waste, nes.,
<br />6.2, PGII .-11§ 44 Gal Tub(Bio) (5.9 cu ft) 5— t. Cu Ft.
<br />UN3291, Regulated Medical Waste, mos., 713214 WTP154 YTY154 )20 Gal Tub(2.7CUFT) 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, P611 VVB434 YWR434 )/WC434 ) Gal Tub(5.7CUFT) Cu Ft.
<br />UN3291, Regulated Medical Waste, non.,
<br />6.2, PGII KR - Biosystems Cardboard Box (4.3 cu ft) Cu FL
<br />UN3291, Regulated Medical Waste, n.o.s.
<br />6.2, P011 SCu 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 of this consignment are fully and accurately TOTALS 5 -Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labened/placarded, and
<br />are In all respects In proper con Rion for transport ac Mg to applicable International and national gov roman I egu
<br />XPrinted/Typed Name Cs.'V-.--V.K.i 0-__0•At\-.S. SIgnatur Date 0 Z Ere, PRIMARY TRANSPORTER TRANSPORTER 1 ADDRESS: Phone if: (888)783-742 Stericyde, Inc. D This is a Through Shipment Applicable Permit Numbers: 4135W. Swift Ave Hauler Re g# 3400 Fresno,CA 93722
<br />TRANSPORTER CEIWTIO so pt of medical waste as descri • • • • • ifir
<br />• r c..V'''' Date c) ca47\
<br />Print/Type Name Signature 40.1....iliallavirlab
<br />N MJ
<br />11
<br />E
<br />l
<br />—
<br />INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone it:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date TRANSPORTER 3 INTERMEDIATE HANDLER INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone it:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. •
<br />Print/Type Name Signature Date 50 TREATMENT FACILITY Genera: svDrre 41.17clatfedt mad?1,:tsta traazV ctity DISCREPANCY INDICATION
<br />)ea. Designated Facility; f
<br />Stericycle, inc. (Autoclave)
<br />7
<br />4135 W. Swift Ave
<br />Proem, CA 53722
<br />tittralas44212Tiz
<br />TSIMIttliE°
<br />OCT 0 2 2020
<br />TREATMENT FACILITY: I certify that
<br />received tiNgiat9dicated wastes in
<br />Print/Type Name
<br />is
<br />I have
<br />accordance
<br />1313. Alternate FacflIty:
<br />Sterlcycle, Inc. (Incinerator)
<br />90 N. Foxboro Drive
<br />North est Lek., UT B4064
<br />mime-1171
<br />. 3A-448/JA-36
<br />been authorized by the applicable
<br />with the requirement outlined
<br />Signature
<br />. 8C. Alternate FacIllty:
<br />Sterlcycle, Inc. (Autoclave)
<br />1651 Shelton Drrve
<br />Hollister, CA 98023
<br />(866)783-7422
<br />TSIOST-83
<br />state agency to accept untreated
<br />in that authorization.
<br />. 130, Alternate Facility:
<br />Covent' Marlon, Inc
<br />4850 Brooklake Road NE
<br />Brooks, OR 0305
<br />(505)393-0890
<br />Permit* 364
<br />medical wastes and that I have
<br />Date
<br />r-i Transferred comainers, cu ft to : Brooks, OR n = Transferred containers, CIJ ft to : N. Sak Lake, UT •
<br />RIGINAL
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