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Stericycle* IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300
<br />1-201.1tG ft : 136 - 13 CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-10.06•STD
<br />MDFROON4JY GENERATOR 1. Generator's Name, Address and Telephone Number
<br />ATTN:Crystal Molina II VAN TRAN, DR RICK DDS INC.
<br />1007 S MAIN ST
<br />NANTECA, CA 95337- 5703
<br />(209) 823-9218
<br />IIIIII111111111111111111111111111111111
<br />3/13/2020
<br />DIN El
<br />CUSTOMER NUMBER 6084572-001 GENERATOR'S REGISTRATION*
<br />2A. DESCRIPTION OF WASTE
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2. PGII
<br />25. CONTAINER TYPE
<br />mg- 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 />6.2, PG11 TB40 - 37 Gal Tub (Rio) (4.9 cu ft) Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII 'TB14 -44 Gal Tub(Blo) (5.9 cu ft) - Cu Ft.
<br />UN329I, Regulated Medical Waste, n.o.s., T821-(.4_)/T1315-(_)/TY154 )20Gal Tub(2.7CUFT a -2 . Cu Ft. 5.2, PGII
<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 W1:343-( )/WP43-( )MC43-( ) 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 ft) Cu Ft.
<br />1JN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII Cu Fl.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII Cu FL
<br />3. Generator's Certification: "I he eby declare that the contents of this consignment are fully and accurately TOTALS
<br />— 1
<br />q° < ' 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 regulations2'
<br />X Printed/Typed Name \I-al kte- KG06(A,Ltil. Signature 2(.121..A...L fl'i.--aik Date 3) I .6 w-d
<br />4. TRANSPORTER 1 ADDRESS: Phone #: (868)787422
<br />Steller*, Inc. 0 This Is a Through Shipment .Applicablo Permit
<br />4135W. Swift Ave Hauler
<br />Fresno CA 93722
<br />TRANSPORT - RTIF - .T .a, ceipt medical waste as • : .ed . • : -
<br />/
<br />. )
<br />Numbers:
<br />Reg# 3400
<br />' 0 a. PRIMARY TRANSPORTER Print/Type Name .— ....21,11130.At Sig : ---"Ilw"....aft.111Mir Date TRANSPORTER 21 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 41:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />Name Signature Date Print/Type 53 TREATMENT FACILITY G""a'rrderp=1.7`91111"da llgr="'''''' DISCREPANCY INDICATION
<br />[)(8A. Designated Facility:
<br />Aftintrv7
<br />—"n" octave)
<br />Fresno, CA 93722
<br />4174 MO
<br />T-
<br />TREATMENT FA TY: I certify that
<br />received the above Indicated wastes in
<br />Print/Type Name
<br />El 135. Alternate Faclilty:
<br />Stericycle, Inc. (Incinerator)
<br />90 N. Foxboro Driv e
<br />North Salt Lake, UT 84054
<br />(801)936-1171
<br />3A-448/JA-36
<br />I have been authorized by the applicable
<br />accordance with the requirement outlined
<br />Signature
<br />. 86. Alternate Facility:
<br />Sterlcycle, Inc. (Autoclave)
<br />1551 Shelton Drive
<br />Hollister, CA 95023
<br />(866)783-7422
<br />TS/OST-83
<br />state agency to accept untreated
<br />In that authorization.
<br />•
<br />medical
<br />Date
<br />80. Alternate Facility:
<br />Covanta Marlon, Inc
<br />4860 Brooklake Road NE
<br />Brooks, OR 97306
<br />(505)393-0890
<br />Pernik* 364
<br />wastes and that I have
<br />in Transferred containers, cu ft to : Brooks, OR C) a Transferred containers, Cu ft to : N. Salt Lake, UT
<br />ORIGINAL
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