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Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1400-424.9300
<br />Route #: 013 - 4 CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-10-08-STD
<br />MDFROO LIOC) PRIMARY GENERATOR TRANSPORTER 1. Generator's Name, Address and Telephone Number
<br />ATTN:Crystal Molina
<br />VAN IRAN, DR RICK DOS INC.
<br />1007 S MAIN ST
<br />l'AANTECA, CA 95337- 5703
<br />(200)
<br />III 1111111111111
<br />823-9218
<br />11 11 11111111111 III I IIIIIIIIIIIIII
<br />1/22/2019
<br />CUSTOMER NUMBER 6084572-001 GENERATOR'S REGISTRATION*
<br />2A. DESCRIPTION OF WASTE
<br />t61,N232P9alli Regulated Medical Waste, n.o.s
<br />2B. CONTAINER TYPE
<br />TB04 - 28 Gal Tub (Bio) (3.7 eu ft)
<br />2C. NO. OF
<br />CONTAINERS
<br />2D. VOLUME
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, ne.s.,
<br />6.2, PGII TB49 -37 Gal Tub (Bo) (4.9 CU ft) Cu Ft
<br />UN3291, Regulated Medical Waste, non.,
<br />6.2, P511 TB14 -" Gal Tub(Bio) (5.9 ct.1 ft) Cu Ft
<br />UN3291, Regulated Medical Waste, n.o,s., TEI214 )/TF154.1e....)/TY15-L, )20 Gal Tub(2.7CUFT)
<br />6.2, PGII Li 5 • Cu Ft
<br />UN3291, Regulated Medical Waste, non.,
<br />6.2, PGII
<br />•
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />6.2, PGII W1343-4 )/INP43-( )ANC43-( ) Gal Tub(5.7CUFT) Cu Ft.
<br />UN3291, Regulated Medical Waste, non.,
<br />6.2, PGII KR - Biosystems Cardboard Box (4.3 cu ft) Cu Ft
<br />UN3291, Regulated Medical Waste, ri.os.,
<br />6.2, PGII Cu Ft
<br />UN3291, Regulated Medical Waste, non.,
<br />6.2, PGII Cu Ft.
<br />3. Generator's Codification: 1 he eby declare that the contents of this consignment are fully and accurately TOTALS 110. -a_ 5 .v\ 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 egulatione
<br />.----,
<br />X Printed/Typed Name CIO SOt 1-0V.1201NO Signature t
<br /> ..—.
<br />Date t 1 2-2-1 VI
<br />TRANSPORTER 1 ADDRESS:
<br />Stericyde, Inc. El This is a Through Shipment
<br />4135 W. %Oft .Aste
<br />Fresno,CA 9 3 7 2 2
<br />Phone #068)783-7422
<br />Applicable Permit Numbers:
<br />Hauler Re g# 3400
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described .
<br />12-1— // 67)1-1.-X, Print/Type Name Nia<., Signature ....---/, .....----- Date ) I
<br />iApplicable
<br />INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Phone fr:
<br />Permit Numbers:
<br />Date
<br />,..,
<br />cc
<br />INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Phone N:
<br />Applicable Permit Numbers:
<br />Date / TREATMENT FACILITY .7,==gtr-gRA4rY I DISCREPANCY INDICATION
<br />St
<br />. Designated Facility:
<br />cycle, Inc. (Autoclave)
<br />41'35 W. Swift AVei
<br />Fresno, CA 93722
<br />(866)783-7422
<br />TS/OST-22
<br />TREATMENT FACILITY: I certify that
<br />received the above Indicated wastes In
<br />Print/Type Name ________Signature
<br />MI
<br />90
<br />Stericycle,
<br />North
<br />(801)336-1171
<br />3A-4413/JA-35
<br />I have
<br />accordance
<br />B. Alternate Facility:
<br />Inc. (Incinerator)
<br />N. Foxboro Drive
<br />Salt Lake, UT 84054
<br />•
<br />been authorized by the applicable
<br />with the requirement outlined
<br />. 8C. Alternate Facility:
<br />Sterlcycle, Inc. (Autoclave)
<br />1551 Shetton Dri\ta
<br />HollIster, CA 95023
<br />(856)783-7422
<br />TS/OST-83
<br />state agency to accept untreated
<br />In that authorization.
<br />Perna # 364-
<br />
<br />813. Alternate Facility:
<br />uova iltistp par ldr116,;. .,,i
<br />4550 5roo a a r° reiTtrr - . E.
<br />Brooks, OR 97305
<br />(505)393-08Ru 0 c1)
<br />—N ' 11 019
<br />medical wastes afifictly$44tve .
<br />Date
<br />tancferredZ. 5 . (.‘ ou ft to : Brooks, OR _-ontainers,
<br />Transferred containers, Cu ft to : N. Sal Lake, UT
<br />ORIGINAL
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