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e:::•Stericycle' INMEtV 51Erty5t6CY_CONgACT: CHEMTREC 1-800-424-9300
<br />CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-10.06-STD
<br />MDFMUM5CF PRIMARY GENERATOR TRANSPORTER 1 Generator's Name, Address and Telephone Number
<br />ATTN:Crystel Molina
<br />VAN TRAN, DR FUCK DDS INC.
<br />1007 S MAIN ST
<br />MANTECA, CA 95337- 5703
<br />(209) 823-9218
<br />11111111111111111111111111111111111111111111
<br />7/5/2019
<br />III 111
<br />CUSTOMER NUMBER 6084572-001 GENERATOR'S REGISTRATION #
<br />2& DESCRIPTION OF WASTE
<br />UN3291, Regulated Medical Waste, n,o.s ,
<br />0.2, PGII
<br />2B. CONTAINER TYPE
<br />TB04 - 28 Gal Tub (BID) (3.7 CU ft)
<br />2c. NO. OF
<br />CONTAINERS
<br />20. VOLUME
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, no.s
<br />6.2, PGII
<br />TB49 - 37 Gal Tub (Blo) (4.9 cu ft)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s
<br />6,2, PGII
<br />T914 -44 Gal Tub(lo) (5.9 Cu ft)
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n.o.s., I LI21 -(1_)/ I P154 )/TY15-( )20 Gal Tub(.11.:UF I)
<br />6.2, PGII I 2 7 Cu Ft
<br />UN3291, Regulated Medical Waste, coo.,
<br />6.2, PGII Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s., WB43-( ANP43-( )ANC43-( ) Gal Tub(5.7CUFT) _ 6.2, PGII Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s
<br />6•2, PGII KR - Biosyslems Cardboard Box (4.3 cu ft) Cu Ft
<br />UN3291, Regulated Medical Waste, n.o.s
<br />6.2, PGII Cu Ft.
<br />UN3291, Regulated Medical Waste, ri.o.s.,
<br />6.2, PGII Cu Ft.
<br />3. Generator's Certification; "1 he eby declare that the contents of this consignment are fully and accurately TOTALS 1 2.-7 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 ndition for transport according to applicable international and national governmental regulations
<br />X Printed/Typed Name Signature 20.2 1
<br />TRANSPORTER 1 Ativnycle Inc. This g Shipment Phone #: Chu / f
<br />ApplicithI Pennit_Nurnigefs; 4135 W. 6vlift Ave e Hauler Regit 3400
<br />Fresno,CA 93722
<br />TRANSPORTER CERTIFICATION: Receipt of medi al waste as describ above
<br />Print/Typo Nameailatki VatiS Signature _..---- Dabo 7 571) TRANSPORTER 2 / INTERMEDIATE HANDLER INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<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 #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Typo Name Signature Date 32 TREATMENT FACILITY Generator Devgnaled regulated rnee4a: waste treamet :ao-ity • and'or elle male regulated WIStEl1roatnent tacit/ DISCREPANCY INDICATION
<br />Di(A. DeeIgnated Facility:
<br />aterIcycle, Inc. (Autoclave)
<br />4135 W, Swift Ave
<br />rrttbri,J, Oh EIT72.2
<br />(8815)7a3-7422
<br />TSIOSII*2•/:ANE ORM
<br />TREATMEN4CPYntify
<br />received the above Indicated fail ds,.4c0a,
<br />Print/Type Name
<br />that
<br />wastes in
<br />0 BB. Alternate Facility:
<br />SterIcycle, Inc. (Incinerator)
<br />90 N. Foxboro Drive
<br />tgorth Qukt Lake, UT 94064
<br />(001)9M-117i
<br />3A-448IJA-36
<br />I have been authorized by the applicable
<br />accordance with the requirement outlined
<br />Sfonature
<br />. BC. Alternate Facility:
<br />Sterlcycle, Inc. (Autoclave)
<br />1661 Shelton Drive
<br />Holli&tor, CA SS023
<br />(866)783-7422
<br />TSIOST-83
<br />state agency to accept untreated
<br />in that authorization.
<br />III SD. Alternate Facility:
<br />Covanta Marlon, Inc
<br />4860 Brooklake Road NE
<br />Brooks, OR MOS
<br />(505)393-0HD
<br />Permit # 3E4
<br />medical wastes and that I have
<br />Date e.T.T...,.. •751.1.-ri - . . • : • s i
<br />0 Transferred containers, Cu fibo '. N. Salt Lake, UT
<br />ORIGINAL
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