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Stericycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300
<br />Route it: 136 - 15 CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-10-06-STD
<br />MDFROOMSUY GENERATOR 1. Generator's Name, Address and Telephone Number
<br />ATTN:Ctystal Molina
<br />VAN TRAN, DR RICK DDS INC.
<br />1007 S MAIN ST
<br />tvANTECA, CA 95337- 5703
<br />(209) 823-9218
<br />1111111111111111111111111111111111E111111111
<br />12/20/2019
<br />CUSTOMER NUMBER 6084572-001 GENERATOR'S REGISTRATION N
<br />2A, DESCRIPTION OF WASTE
<br />UN3291. Regulated Medical Waste, n.o.s
<br />6.2, PGII
<br />28. CONTAINER TYPE
<br />TRU -28 Gal Tub (Rio) (3.7 cu ft)
<br />2C. NO. OF
<br />CONTAINERS
<br />2D VOLUME
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, rues.,
<br />6.2, PGII TR49 -37 Gal Tub (Bio) (4.9 cu ft) Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII T814 -44 Gal Tub(Blo) (5.9 CU ft) Cu Ft.
<br />UN3291, Regulated Medical Waste, rues., T21-(\ )/TP15-( )/TY15-( )20 Gal Tub(2.7CUFT)
<br />62, PGII Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s
<br />6.2, PGIl Cu Ft.
<br />UN3291, Regulated Medical Waste, rues.,
<br />6.2, PGII WE343-( )/WP43-( )NVC43-( ) Gal Tub(5.7CUFT) Cu Ft.
<br />UN3291, Regulated Medical Waste, rues.,
<br />6.2, PGII KR - Biosystems Cardboard Box (4.3 cti ft) Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s
<br />6.2, PO 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 of this consignment are fully and accurately TOTALS ili. c...,9 ? Cu Ft
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded,
<br />are In all respects In proper condition for transport according to applicable International and national governmental
<br />. / i *it,
<br />X Printed/Typed Name 11 i Signature
<br />and
<br />egulallo "
<br />Date PRIMARY TRANSPORTER TRANSPORTER 1 ADDRESS'
<br />Stencycle, Inc. 0 This is a Through Shipment
<br />4135 W. Swift Ave ,
<br />Fresno,CA 93722
<br />Phone 4: (13t113)183-1422
<br />Applicable Permit Numbers:
<br />Hauler Reg# 3400
<br />TRANSPORTE ICA N4 : yer-ttpt ol m dical waste as describe
<br />Print/Type N e ‘-le( Signature - Data /2 ...L0 . TRANSPORTER 2/ INTERMEDIATE HANDLER INTERMEDIATE LEA 2 / TRANSPORTER 2 ADDRESS:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />• Print/Type Name Signature
<br />Phone 4:
<br />Applicable Permit Numbers:
<br />Date TRANSPORTER 3! INTERMEDIATE HANDLER INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Phone 4:
<br />Applicable Permit Numbers:
<br />Date 79 TREATMENT FACILITY 9"`"=,"t=b"jr DISCREPANCY INDICATION
<br />Designated Facility:
<br />Stericycle, Inc. (Autoclave)
<br />4135 W. Swift Ava
<br />Preono, CA 511722
<br />(15155)7-7422
<br />TS/OST-22
<br />DAt,E ANNE offre
<br />TKATJA411 ;,.., ITY: I certify that
<br />received tfare-a ,1` bi dicated wastes in
<br />Print/Typabkitfica,
<br />D 8B. Altemate Facility:
<br />Sterlcycle, Inc. (Incinerator)
<br />90 N. Foxboro Drive
<br />Worth Si A 1..s1c4 , UT 414(1E4
<br />(801)9M-1171
<br />3A-448/JA-35
<br />I have been authorized by the applicable
<br />accordance with the requirement outlined
<br />Signature
<br />a 8C. Alternate Facility:
<br />SterIcycle, Inc. (Autoclave)
<br />1551 Shalton Dtiv
<br />Holcister, CA 95023
<br />(865)783-7422
<br />TS/OST-83
<br />state agency to accept untreated
<br />in that authorization.
<br />.
<br />medical
<br />Date
<br />80. Alternate Facility:
<br />Covanta Marlon, Inc
<br />4E60 Erooktalta Road NE
<br />Brooks, OR 97305
<br />(5(15)393-0890
<br />Permit # 364
<br />wastes and that I have
<br />il ittThi—MntairierS, cu ft to : Brooks, OR C
<br />0 Transferred containers, Cu ft to : N. Salt Lake, UT.
<br />ORIGINAL
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