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:::*Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300
<br />Route #: 134 — 15 CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST oet-io-os-STO
<br />MDFROOMJ00 GENERATOR 1. Generator's Name, Address and Telephone Number
<br />ATTN:Crystal Molina III VAN TRA N, DR RICK DDS INC.
<br />1007 S MAIN ST
<br />MANTECA, CA 95337-5703
<br />(209) 823-0218
<br />11111111111111111 1 1111111111111111111111
<br />10/18/2019
<br />IN
<br />CUSTOMER NUMBER 6084572-nni GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />2B. 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, n.o.s.,
<br />6.2, P511 TB49 - 37 Gal Tub (Blo) (41 cu ft) Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s
<br />6.2, PGII TB14 -44 Gal Tub(Bio) (5.9 co ft) Cu Ft.
<br />UN329I, Regulated Medical Waste, n.o.s
<br />6.2, PGII TB214 y-r-P154 )/TY154 )20 Gal Tub(2.7CUFT) 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 WR43-( ythIP43-( ) Gal Tub(5.7CUFT) ...,...)/wc4.34 Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII KR . eiclaysifmq Cardboard Box (4 3 cu It) 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, PG11
<br />.
<br />ell() Cu Ft.
<br />3. Generator's Certification: "I he eby declare that the contents ol this consignment are fully and accurately 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 condition for transport according to applicable International and national governmental egulatIons."
<br />X_PrintediTyped Name Signature Date PRIMARY TRANSPORTER TRANSPORTER I ADDRESS:
<br />Stericycie, Inc.
<br />4135W. Swift Ave
<br />Fresna,CA 93722
<br />TRANSPORTE; RT1. • ION: ecelpt of medical waste as described
<br />eiff'
<br />•
<br />Phone #: (868)783-7422
<br />This is a Through Shipment Applicable Permit Numbers:
<br />Hauler Reg# MOO
<br />above. 'VOW ' a _dale- Date Print/Type Name 1 I OW. Signature TRANSPORTER 2/ INTERMEDIATE HANDLER INTERMEDIATE HANDLER 2/ TRANSPORTER 2 ADDRESS: Phone 4:
<br />Applicable Permit Numbers: ,
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />print/Type Name Signature Date TFIANSPORTER 3 INTERMEDIATE HANDLER INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone If:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date II TREATMENT FACILITY Generator Devgnated regulated enedsca/ waste treatment lactly ondIcr eaten-sale reguirel waste treatment Slaty DISCREPANCY INDICATION
<br />III
<br />TREATMENT
<br />received
<br />Print/Type
<br />8A. Designated Facility:
<br />Stericycle, Inc. (Autoclave)
<br />413s W. Swift Ava
<br />Fresno, CA 93722
<br />(866)783..7422
<br />TS/OST-22
<br />FACILITY: I certify that
<br />the above indicated wastes in
<br />Name
<br />.
<br />I have
<br />accordance
<br />BB. Alternate Facility:
<br />Stericycle, Inc. (Incinerator)
<br />90 N. Foxboro Dm
<br />North Salt Lake, UT 84054
<br />(801)936-1 171
<br />3A-448/JA-36
<br />been authorized by the applicable
<br />with the requirement outlined
<br />Signature
<br />. BC. Alternate Facility;
<br />Stencycle, Inc. (Autoclave)
<br />issi shalton Div*
<br />HollIster, CA 95023
<br />(866)783-7422
<br />TS/OST-83
<br />slate agency to accept untreated
<br />In that authorization.
<br />.
<br />medical
<br />Date
<br />813. Alternate Facility:
<br />Covanta Marlon, Inc
<br />4850 Brooklaka Road N
<br />Brooks, OR S7305
<br />(865)393-M8D
<br />Permit # 364
<br />wastes and that I have
<br />--1
<br />D Transferred containers, cu ft to : Brooks, OR
<br />D
<br />Transferred containers, cu ft to : N. Sall Lake, UT
<br />ORIGINAL
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