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IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300
<br />Route #: 023 — 6 CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-10-06-STD
<br />MDFROOKIiRD
<br />e, Address and Telephone Number
<br />N:Mary Nguyen
<br />DR RICK DDS INC.
<br />ST
<br />95337- 5703
<br />. III 1111111111111111111111111111111101111111111111111
<br />(209) 823-9218 8/14/2018
<br />/6084572-001 GENERATOR'S REGISTRATION #
<br />/410N OF WASTE
<br />;,,i(gulatod Medical Waste, n.o.s,,..1304 ,411
<br />2B. CONTAINER TYPE
<br />, — 28 Gal Tub (Bio) 3.7( cu ft)
<br />2C. NO. OF
<br />CONTAINERS
<br />2D. VOLUME
<br />Cu Ft.
<br />f396111 Regulated Modical Waste, n o s --(.1349 — 37 Gal Tub (Bio) (4 , 9 cu tt) Cu Ft
<br />f,9o1li Regulated Medical Waste, n.o.s.": — 44 Gal Tub (1310) (5. 9 cu ft) Cu Ft
<br />291 Regulated Medical Waste, n.o.s.,
<br />PG II ) /TP15— ( )/TY15—( )20 Gal Tub (2 . 7CUFT) T7 Cu Ft
<br />291, Regulated Medical Waste, n.o.s.,
<br />PG11 Cu Ft.
<br />291, Regulated Medical Waste, non.
<br />0311
<br />n34 ) /14843— ( ) /wc43— ( ) Gal Tub (5 . 7CUPT ) 3— ( cu Ft.
<br />91 Regulated Medical Waste, n.o.s
<br />GII 'KR_ — Biosymtems Cardboard Box (4.3 cu ft) Cu Ft.
<br />?91, Regulated Medical Waste, non.,
<br />GII Cu Ft,
<br />191 Regulated Medical Waste, n.o s.,
<br />'Gil Cu Ft
<br />.3enorator's Certification:I he eby declare that the contents of this consignment are fully and accurately TOTALS 110. 2 f/ Cu Ft.
<br />scribed above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />i In all respects in proper condition for transport according to applicable international and national gover • e tel egulations.'
<br />1 / i (Printed/Typed Name A l1 l a ' Signature L..I lei ..1,011112 ate 2"-- 1LI /
<br />RANSFORTER I ADDRESS: Ph°W66) 783-7922
<br />Stericycie, Inc. 11 This is a Through shipment Applicable Permit Numbers'
<br />4135 W. Swift Ave Hauler Reu# 3400
<br />Frezno,CA 93722
<br />kNSPORTE .. t..., —ERT1FICAT ON: Receipt o edlcal waste as described a.ove. 0
<br />821111g
<br />/Type NameL --0\M. i Signature AM& 411. Date
<br />TEF1MEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS. Phone if:
<br />Applicable Permit Numbers
<br />ERMED1ATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />!Typo Name SIgnatum Date
<br />ITERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone :
<br />Applicable Permit Numbers:
<br />ERMED1ATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />hype Name Signature Date
<br />ISCREPANCY INDICATION
<br />A. Designated Facility: 0 El13, Alternate Facility: . 80, Alternate Facility: . 813. Alternate Facility:
<br />ncycle, Inc. Stencycle, Inc. Stertcycle, Inc. Coventa Marlon, Inc
<br />5W, Swift Ave SO N. Foxboro Drive 1561 Shelton Drive 4860 Brooklake Road NE
<br />ano, CA 93722 North Salt Lake, UT 84054 Hollister, CA 95023 Brooke, OR 97305
<br />6)783-7422 (301)936-1171 (866)783-7422 (506)393-0890
<br />0 ST-22 Diti-g MOE °FIT11 2A -44841A-36 TSIOST-83 Permit # 364
<br />EATMENT FAclizi1:4,011011that I have been authorized by the applicable state agency to accept untreated medical wastes and thathave
<br />skied theabtataqd cared-XaNtes in accordance with the requirement outlined in that authorization.
<br />VType Name Signature Date
<br />
<br />Transferred containers, CU ft to:
<br />ORIGINAL
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