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Stericycle' IN tyogt4 EyyRaEilleY cONTHT: CHEMTREC 1-800-424-9300
<br />CUSTOMER NO. 21132
<br />9/27/2019 (209) 823-9218
<br />CUSTOMER NUMBER 6084572-001 GENERATOR'S REGISTRATiON k
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Print/Type Name
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Signature Date
<br />Phone it:
<br />°Applicable Permit Numbers:
<br />Print/Type Name Signature Date
<br />El SC. Alternate Facility:
<br />Stericycle, Inc. (Autoclave)
<br />1651 Shelton Drive
<br />Hollister, CA 95023
<br />(666)783-7422
<br />TS/OST-S3
<br />LI 80. Alternate Faculty;
<br />Covanta Marlon, Inc
<br />4850 Brooklake Road
<br />Brooks, OR 97305
<br />(505)393-0890
<br />Permit # 364
<br />BA. Designated
<br />SterIcycle, Inc. (Autoclave)
<br />4106 W. GwittAve
<br />Fresno, CA 93722
<br />(886)783-7422
<br />TEgtcra-AsE 0 Fvfli
<br />El ail Alternate Facility:
<br />stericycle, Inc. (Incinerator)
<br />90 N, Foxboro Drive
<br />North Salt Lake, UT S4054
<br />(8009,36-1 171
<br />2A-40/JA-36
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:erystal Molina
<br />VAN TRAN, DR RICK DDS INC.
<br />1007 S MAIN ST
<br />MANTECA, CA 95337- 5703
<br />1111111111111111111111111111111111111111111111111111
<br />2A. DESCRIPTION OF WASTE
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste,
<br />6.2, P011
<br />2B. CONTAINER TYPE
<br />T804 - 28 Gal Tub (Blo) (3.7 Cu ft)
<br />1849 - 37 Gal Tub (Bio) (4.9 CU ft)
<br />20. NO. OF 20. VOLUME
<br />CONTAINERS
<br />Cu Ft.
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6 2, PG11
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGI1
<br />UN3291, Regulated Medical Waste, n,o,s.,
<br />6.2, PG11
<br />TE1-14 -44 Gal Tub(lo) (5.9 cu ft)
<br />I Ern 2—)TTFT 1--( )20 Gal Tu1(2.7CUFT)
<br />VVB43-( )AA/P43-( VINC43-( ) Gal Tub(5.7CUFT) GENERATOR Cu Ft.
<br />Cu Ft.
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />62, PG11
<br />KR - Biosystems Cardboard Box (4.3 cu ft)
<br />Cu Ft.
<br />Cu Ft.
<br />3. Generator's Certification: "1 he eby declare that the contents of this consignment are fully and accurately TOTALS Cu Ft.
<br />described above by the proper sh pi:kg 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 vfReentol ogulat
<br />X Printed/Typed Name Nato
<br />TRANSPORTER 1 ADtFIR,ycL.
<br />4135 W. Sylift Ate
<br />Fresno,CA 93722
<br />0 This is aT eugh hipment
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Rm2)12/K.) Lt (Pa/Yr-a- Signature
<br />INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> ("BM Phone ti: . •
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />7. DISCREPANCY INDICATION
<br />TREATMet17 FIACI certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received thoi above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Narma-4-d"' /(11!? Signature Date
<br />Transferret ma-diners, cu ft to . Brooks, OR
<br />Transferred containers, cu ft to : N. Salt Lake, UT
<br />ORIGINAL
<br />Date
<br />5. Cu Ft.
<br />Signature
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD W/s1IFTZiOir-STD
<br />MDFRL
<br />ApplIci° P Tar'ilk—TVeAerS.400
<br />Phone
<br />Applicable Permit Numbers:
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