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• e.e.• Stericycle6 -1)-1/ RgkicaE jit EyERGENCY bCONTACT: CHEMTREC 1-800-424-9300 b CUSTOMER NO.21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-10-0E-STD
<br />MDFROOLTOS GENERATOR 1. Generator's Name, Address and Telephone Number
<br />ATTN:Cfystal Molina
<br />VAN TRAN, DR RICK DOS INC.
<br />1007 S MAIN ST
<br />MANTECA, CA 95337- 5703 . (209) 823-9218
<br />1111111111111111111111111111111
<br />4/12/2019
<br />CUSTOMER NUMBER 60E44572-001 GENERATOR'S REGISTRATtON #
<br />2A. DESCRIPTION OF WASTE
<br />UN3291, Regulated Medical Waste, n.o.s.
<br />6.2, PGII
<br />213, CONTAINER TYPE
<br />TB04 -28 Gal Tub (Rio) (3.7 cu ft) ..
<br />2C, No. OF
<br />CONTAINERS
<br />20. VOLUME
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />5.2, PGII TI349 - 37 Gal Tub (Rio) (4.9 cu ft) Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />6.2, PGII TBI4 -44 Gal Tub(Blo) (6.9 cu ft)
<br />Cu Ft. -
<br />UN3291, Regulated Medical Waste, n.o.s,, T1321 154 yrvis-t go siTubv. /cur I) )ri 6.2, PGII Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s ,
<br />6.2, PGII Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s., wB43,4 yvvp43,4_wic4,34. ) Gal Tub(5.7CUFT) 6.2, PG11 Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />6.2, P6I1 KR - Biosystems 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, PGII Cu Ft.
<br />3. Generator's Certification: "I he eby declare that the contents of this consignment are fully and accurately TOTALS t. I\ Cu Ft.
<br />described above by the proper shipping
<br />are in all re cts i proper condition
<br />X.Prin .
<br />name, and are classified, packaged, marked and labelled/placarde , . d
<br />for tr nsport according to applicable International and national gem , tail e:
<br />if
<br />---. Signature a
<br />r
<br />ti• s."
<br />Date9 1
<br />1,
<br />1) )5 \ PRIMARY TRANSPORTER TR ANSPOR
<br />Print/Type Name
<br />4135
<br />Fres
<br />TRANSPORTE edical
<br />dikafili , Inc.
<br />W. Swift
<br />9,
<br />ERTI CAT
<br />k .,/-1/
<br />Are
<br />72
<br />: Receipt of m waste as described
<br />Signature
<br />• —. t Phone This i s a hrough pment Applicable Permit Numbers:
<br />Hauler Re gO 3400
<br />.
<br />\
<br />Date TRANSPORTER 2/ INTERMEDIATE HANDLER INTERMEDIATE HANDLER 2 / TRANSPORTE
<br />INTERMEDIATE HANDLER /TRANSPORTER
<br />Print/Type Name
<br />ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />CERTIFICATION: Receipt of medic- 'was as described above.
<br />Signature Date TRANSPORTER 3/ INTERMEDIATE HANDLER 5. 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/Type Name Signature Dale 44 TREATMENT FACILITY Genera), Des,nted rezited rearsul tre.:2 trearnenV.IV4 a-d'or ozonwo regLiaed cage treatment bay 7. DISCREPANCY INDICATION
<br />DednIptiOlkari
<br />Ste -14): inc. (Autoclave)
<br />4 i 36 W. Swat AvA nnita
<br />Weroms, M*1' i.IX, LU
<br />(6611776VT42z
<br />TS/OST-22 .0,40104
<br />TREATMENT FACILITY: I certify that
<br />received the above indicated wastes in
<br />Print/Type Name
<br />-------i
<br />n 8B. Alternate Facility;
<br />-.. . inc. (Incinerator)
<br />90 N. cot ore Drive
<br />Notill Os ik Lek*, UT 94044
<br />(301)935-1171
<br />3A-44841A-36
<br />I have been authorized by the applicable
<br />accordance with the requirement outlined
<br />S
<br />ihhffrfia
<br />totraiar_rti
<br />,
<br />. 8.c. Alternate Facility;
<br />SterIcycle, Inc. (Autoclave)
<br />1561 Shelton WW1
<br />Holkikurr, CA 56023
<br />(B66)733-7422
<br />'TS/OST-83
<br />state agency to accept untreated
<br />In that authorization.
<br />. 80, Alternate Facility;
<br />Combs Marlon, Inc
<br />4350 Brooidake Road NE
<br />Smoke, OR 97305
<br />1505)393-D89D
<br />PerrnIt # 364
<br />medical wastes and that I have
<br />Date
<br />Transferred containers, Cu ft to : N. Sek Lake, UT
<br />ORIGINAL
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