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<br />4:0 Stericycle*
<br />PlourtnftWeiiashvilA
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-1300-424-9300
<br />Route # 023 - CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST OD1-10-06-STD
<br />MDFROOKA1B , . GENERATOR 1. Generator's Name, Address and Telephone Number
<br />ATTN:Mary Nguyen
<br />VAN TRAN, DR RICK DDS INC.
<br />1007 s MAIN ST
<br />MANTECA, CA 95337- 5703
<br />(209)
<br />III IIIIIIIMIIIII
<br />823-9218
<br />ll It I II MINN I lilt
<br />2/27/2018
<br />IIIIIIIII
<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 />2 B. CONTAINER TYPE
<br />TB05 - 40 Gal Tub (13io) (5 .3 cu ft)
<br />2C. NO. OF
<br />CONTAINERS
<br />2D VOLUME
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n os.,
<br />6.2, PGII
<br />T049 - 37 Gal Tub (131.0 (4, 9 cu -Et)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />6,2, PGIl
<br />T814 - 44 Gal Tub (Bit (S. 9 cu ft)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n us.,
<br />6.2, PG11
<br />• doitaelP0.) /trP1-3- (path) / TY.1.5- (chszmo) 20 Gal rub (2 __icupx)
<br />Cu FL
<br />UN3291, Regulated Medical Waste, Bas,,
<br />6.2, P611
<br />1031- (Bie),NP31- (P(1 th),A1C31- (Cheerio) 3.1. Gal Tub (4..14C1IFI )
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.e.s.,
<br />6.2, MI ti- (Edo) ./PW4 3-- (path) /Cit142- (Chelan) Gal Tub (5 ..7CUFT) Cu Ft.
<br />UN3291, Regulated Modica' Waste, n.o.s..
<br />6.2, PGII MB - Biosystems Cardboard Box (4 _2 cu ft)
<br />— 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
<br />'
<br />Cu Ft.
<br />3. Generator's certification:1 he eby declare that the contents of this consignment are fully and accurately TOTALS 0. )-' I Cu Ft.
<br />described above by the proper shlpp!p name and are cfassIfled packaged, marked and labelled/placarded, and
<br />are in all respects In proper condlt r tran ort according to applicable International and national government: a t ations."
<br />ix; ,,. rot-- ,
<br />-i)17-1/ p Dabs?' ' Printed/Typed Name / •-<7 Signature PRIMARY TRANSPORTER Ste
<br />4135
<br />TRANSPORTER C •
<br />PrEntiType Name
<br />TRANSPORTER 1 ADORES
<br />Ftesno,CA
<br />t:icyc le, Inc. D This is a Tnro g h shipment
<br />W. SWift Ave
<br />93722
<br />IFICATIO - . -eceipt of ./ cal waste as descrtbed ab e.
<br />111./A....._ ..... Signature Date
<br />phone it (6 os.:.•)
<br />Applicable Permit Numbers:
<br />Hauler Reg# 3400
<br />7 )1f
<br />cJW
<br />00 -
<br />INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medrcal waste as described above.
<br />PrIntrrype Name Signature
<br />Phone II:
<br />Applicable Permit Numbers:
<br />Date TRANSPORTER 31 INTERMEDIATE HANDLER 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 4:
<br />Applicable Permit Numbers:
<br />Date TREATMENT FACILITY 5""t, DesSnalednirmEml Nast, Tvareri tacky ardor aternak fa:212W vast, terreri DISCREPANCY INDICATION
<br />y
<br />TREATMENT
<br />received
<br />FrInt/Type
<br />A. Designated Facility:
<br />Stericycle, Inc. '
<br />4135w4e4,
<br />Fresno,
<br />(886)73-7422
<br />TSICIg 27 zoia
<br />FAOri-111+.141r ify that
<br />the above indicate. wastes in
<br />Name
<br />. OB. Alternate Facility:
<br />Stericycle, Inc.
<br />90 N. Foxboro Drive
<br />North Salt Lake, UT 84054
<br />(801)936-1 171
<br />3A-4480A-36 '
<br />I have been authorized by the applicable
<br />accordance with the requirement outlined
<br />Signature
<br />1111 80. Alternate Facility:
<br />Stericycie, Inc.
<br />1551 Shetton Drtve
<br />Hollister, CA 95023
<br />(866)783-7422
<br />TSiOST-33
<br />state agency to accept Untreated
<br />in that authorization.
<br />. 813. Alternate Facility:
<br />o tvtarion,Inc Cvanta
<br />4850 Brooklake Road NE
<br />Brooks, OR 97305
<br />(505)3934380
<br />Perrnit# 384
<br />medical wastes and that I have
<br />Date
<br />41 Transferred eattliliht.,114, c4.1 11 to .
<br />ORIGINAL
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