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0;:.• Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300
<br />CUSTOMER NO. 21132
<br />•
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-10-06-STD TRANSPORTER 2 / PRIMARY INTERMEDIATE GENERATOR HANDLERTRANSPORTER AVW Id 1.11. W . .1.-) ...1 .1..,
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:Crystal Molina 1111113111111111111111111111111 VAN TM, DR RICK DOS WC.
<br />1007 S MAIN ST
<br />MANTECA, CA 95337- 5703
<br />(204) 823-9218
<br />1.11JV [WU LiLil....11
<br />5/21/2019
<br />CUSTOMER NUMBER 60$1157,-nni
<br />2A. DESCRIPTION OF WASTE
<br />1JN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />GENERATOR'S REGISTRATION #
<br />2B. CONTAINER TYPE
<br />TIM - 28 Gal Tub (ale) (3 7 cu ti)
<br />20. NO. OF
<br />CONTAINERS
<br />2D. VOLUME
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />6.2, PGII TB49 - 37 Gal Tub (Bic) (4.9 cult) Cu Ft
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII ; 14 -44 Gal Tubdtio) (5.9 Cu ft) Cu Ft
<br />1JN3291, Regulated Medical Waste, n.o.s,,
<br />6,2, PGII
<br />Aor
<br />. 15-(_)/TY15-( )20 Gal Tub(2.7CUFT) Cu Ft
<br />1tN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII INB434 ANPA3.4 w/c,434 Gal Tub(5.7CUFT) Cu Ft
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII KR -Biosystems Cardboard Box (4.3 cu It)
<br />. ..
<br />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 Cu Ft
<br />Generator's Certification; I he eby declare that the contents of this consignment are fully and accurately
<br />described above by the proper shipping name, and are classified, packaged, marked and labeged/placarded, and
<br />are in all respects in proper condition for transport according to applicable International and national governmental
<br />X Printed/Typed Name 14P42"11 ry P1M12-P-0 Signature
<br />TOTALS 2- 7— Cu Ft.
<br />egulatIons."
<br />Dale 6—'7 5) 1 cr -
<br />TRANSPORTER 1 ADDRESS; Phone #'
<br />8
<br />Stericyde, Inc. 13 This is a Through Shipment Apogee 63(1)M,71,0
<br />4135W. Swift Aue Haubr Reg!" 3400
<br />Fresno,CA 93722
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above •
<br />1
<br />Print/Type Name Signature Date
<br />INTERMEDIATE HANDLER 2 / TRANSPORT 2 ADDRESS: Phone ff.
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medtcal waste as described above.
<br />Print/Type Name Signature Date 00195 - TREATMENT FACILITY TRANSPORTER 31 INTERMEDIATE Generalv=leregulalt meckal wasle Ur-Anent taaLry 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 Data
<br />DISC ANCY INDICATION
<br />8A. Designated Facility:
<br />SterIcycle, Inc. (AubDclave)
<br />4135 VV. SOAR Ave
<br />Fresno, CA 0722
<br />(866)783-742 ANNE (WO i801)936-1171
<br />TS/OST-24 -- '
<br />TREATMM,FAct1,1Tffirertify that
<br />d received triliUboCte'rndffa e wastes In
<br />Print/Type Name
<br />MI 88. Alternate Facility; 111 BC, Alternate Facility:
<br />(Autoclave)
<br />Drive .
<br />to accept untreated
<br />in that authorization.
<br />II 80. Alternate Facility;
<br />Inc
<br />Road NE
<br />97305
<br />and that I have
<br />Stericycle, Inc. (Incinerator)
<br />90W, Foxboro Drive
<br />North Salt Lake, UT 84054
<br />3A-448/JA-36
<br />I have been authorized by the applicable
<br />accordance with the requirement outlined
<br />Signature
<br />Stencycle, inc.
<br />1661 Shelton
<br />Hollister, CA 95023
<br />(866)783-7422
<br />TS/OST-83
<br />state agency
<br />Coverts Merlon,
<br />4850 Brooklake
<br />Brooks, OR
<br />(505)393-0890
<br />Permit* 364
<br />medical wastes
<br />Date ___________
<br />Transferred
<br />Transferred
<br />containers. cu ft to : Brooks, OR
<br />Sal Lake, UT containers, cu ft to : N.
<br />ORIGINAL
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