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Stericyclee IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300
<br />Route IS: 023 — 6 CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001.10-06-STD
<br />MDFROOKLG2 GENERATOR 1. Generator's Name, Address and Telephone Number
<br />ATTN:Mary Nguyen 11111111111111111111111111111111111111111111111 VAN TRAN, DR RICK DDS INC.
<br />1007 S MAIN ST
<br />MANTECA, CA 95337- 5703
<br />(209) 823-9218 5/22/2018
<br />CUSTOMER NUMBER 6084572-001 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />UN3291, Regulated Medical Waste, 11,0,5.,
<br />6.2, PGII
<br />2B. CONTAINER TYPE
<br />TB04 — 28 Gal Tub (Bic)) (3 ."7 Cu ft)
<br />2C. NO. CF
<br />CONTAINERS
<br />2D. VOLUME
<br />Cu Ft.
<br />UN32911 Regulated Medical Waste, n.o.s„
<br />6.2 , PGI
<br />TB4 9 _ 37 Gal Tub (Bit)) (4.9 cu tt) Cu Ft
<br />U1J32911 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII TB14 — 44 Gal 'Mb (Bi.o) (5. 9 cu tt) Cu Ft.
<br />UN3291, Regulated Medical Waste, a o.s., T52.1.— ( ) /TP1.5 — ( ) / 17.1.5 — ( )20 Ga1 Tub (2 .7CLIFT) ___ 6.2, pGII 0 Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s,,
<br />6.2, PG11
<br />1111/11:-1----
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n,0 s
<br />6.2 Pali , san43- ( )/WP42- ( )/wo43— ( ) Gal Tub 1.5 .7OlIFT) ..------ Cu Ft.
<br />UN3291, Regulated Medical Waste, n.e.s ,
<br />6.2, PGII '
<br />—
<br />KR — Biosystetaz Cardboard Box (4.3 cu ft) Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s,
<br />6.2, PGII Cu Ft.
<br />IJN3291, Regulated Medical Waste, n.o.s ,
<br />62, P1311 Cu Ft
<br />3. Generator's Certification: 1 hereby declare that the contents of this consignment are fully and accurately TOTALS Cu Ft.
<br />are in all respects in pave
<br />X, PrintedflYped Name
<br />described above by the prop w
<br />on
<br />hipping name, and • 'attled, packaged, g arked and labelled/placarded, and
<br />Allen" tr- sport coon ng to applicable I, e national a i national governmental egulations,"
<br />Signature A Date II' PRIMARY ' TRANSPORTER TRANSPORTER -I ADDRiS: Phon(866) 783-74-
<br />Stericy le, Inc. Thiz is a Through shipment Applicable Permit Numbers:
<br />4135 W. Swift Ave Hauler Reg# 3400
<br />Fresno,CA 93722
<br />TRANSPORTERTIFICATIO -eceipt of m:ilcal waste as described above, Lset
<br />2
<br />
<br />I Jr I PrintrlYpe Name L. Signature I ' Date (C r TRANSPORTER 2/ INTERMEDIATE HANDLER INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone it:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medtcal waste as described above.
<br />Print/Type Name Signature Date TRANSPoRTER 3 / INTER MEN ATE HANDLER INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone it
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Prinntpe Name Signature Dale TREATMENT FACILITY ocntoac=ii =twit* tra4 trozhwritaCay I DISCREPANCY INDICATION •
<br />. DA. Doelonntod Facility:
<br />SterIcycle, Inc.
<br />4185 W. Swift Ave
<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/1We Name
<br />III 813. Alternate Facility:
<br />Stericycle. Inc.
<br />90 N. FOXbOrO Drtve
<br />North Salt Lake, UT 84054
<br />(801)936-1171
<br />3A-4481,1A-36
<br />I have been authorized by the applicable
<br />accordance with the requirement outlined
<br />- Signature
<br />ill 13C. Alternate Facility:
<br />Stericycle, Inc.
<br />1551 Shelton Drive
<br />Hollister, CA 95023
<br />(866)783-7422
<br />TSIOST-83
<br />state agency to accept untreated
<br />in that authorization.
<br />II
<br />medical
<br />Dale
<br />8D. Alternate Facility:
<br />Covanta Marion,Inc
<br />4850 Elrooklake Road NE
<br />Brooks, OR 97305
<br />(505)393-0890 .
<br />Permit* 364
<br />wastes and that I have
<br />Tra figft rrei d containers, MI It to
<br />7,1
<br />ORIGINAL
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