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<7.) Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300
<br />Route CI 136 — 5 CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-10-0E-STD
<br />MDFRO 00 PRIMARY TRANSPORTER GENERATOR 1. Generator's Name, Address and Telephone Number
<br />. ATTN:Crystal Molina
<br />VAN IRAN, DR RICK DDS INC.
<br />1007 S MAIN ST
<br />MANTECA, CA 95337- 5703
<br />(209)
<br />III
<br />823-9218
<br />11111111111111111111111111 111
<br />3/12/2021
<br />1111111111E
<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 />2B. CONTAINER TYPE
<br />TE104 - 28 Gal Tub (Rio) (3.7 eu ft)
<br />2C. NO, OF
<br />CONTAINERS
<br />2D. VOLUME
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste,I.o.s.,
<br />6.2, PGII TB49 -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(Rio) (5.9 cu It) Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s., TB21-(7/_)/715-( )1)11Y1-(5 )20 Gal Tub(2.7CUFT)
<br />/
<br />6.2, PGII 7Cu Ft. igY 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 34 NVP43-( )/WC43-( ) Gal Tub(5.7CUFT) Cu Ft.
<br />UN3291, Regulated Medical Waste, n,o.s.,
<br />6.2, PGII KR - Biosysterns Cardboard Box (4.3 cu ft) _ 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 Cu Ft.
<br />3. Generator's Certification: "I he eby declare that the contents of this consignment are fully and accurately TOTALS
<br />/ Cu Pt.
<br />described above by the proper shipping name, and are classified, packaged,
<br />are in alt respects in proper condition for transport according to applicable
<br />X Printed/Typed Name
<br />marked and labeiled/placarded, and
<br />international arid national governmental egutations."
<br /> Signature ._.AAlakot%-- . - Date
<br />TRANSPORTER 1 ADDRESS:
<br />Ste
<br />F sno,
<br />TRANSPOR !. i -
<br />2 i .
<br />Print/Type Nam
<br />i
<br />.
<br />IF
<br />41
<br />
<br />Inc. 0 T4115
<br />9 P 2
<br />
<br />/
<br />.,
<br />CAT d ' :. : pt • medNl waste as describe. ove.
<br />i i i ,, , dil, I 1 " , Signalure iPr .4M...4. ..M1 . ,
<br />is a Thri ! ipment
<br />4IP 4.4
<br />Phone #: (866)783-7 2
<br />Applicable Permit Numbers:
<br />Hauler Reg% 3400
<br />Date -......... 1M.. ,,... A ••• •
<br />-
<br />uJ 2
<br />1
<br /> is ,
<br />-
<br />INTERMEDIATE HANDLER 2 /TRANSP TER 2 ADDRESS:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Data TRANSPORTER 3/ INTERMEDIATE HANDLER 6, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt el medical waste as described above.
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Cato Name Signature PrintiType )_6 TREATMENT FAC)147 C...negata=r=edgetitziehnen, I .oiriy 7. DISCREPANCY INDICATION
<br />sIgnated Facility:
<br />'157cycle, Inc. (Autoclave)
<br />4136 W. Sviittt Avo
<br />'custom", CA 83722
<br />(845)783-7422ALE ANNE ORTiZ
<br />TS/OST-22 AUTOCLAVED
<br />MAR 12 2021
<br />TREATMENT FACILITY: I certify that
<br />received the abovcgidi9,4Wwastes in
<br />Print/Type Name
<br />• ill
<br />90
<br />SterIcycle,
<br />North
<br />(001)939-1171
<br />3A
<br />I have
<br />accordance
<br />BB. Alternate Facility:
<br />Inc. (Incinerator)
<br />N. Fothoro Drtvi
<br />cisit Lake , UT 94064
<br />-4418/1A-36
<br />been authorized by the applicable
<br />with the requirement outlined
<br />Signature
<br />E 0G. Alternate Facility:
<br />Stencycle, Inc. (Autoclave)
<br />1661 Stratton Ott*
<br />HvIllater, CA 95023
<br />(855)783-7422
<br />TSIOST-83
<br />state agency to accept untreated
<br />in that authorization.
<br />Alteate Facility: In aft m
<br />Covanta Marlon, Inc
<br />4660 Brooidakt Road NE
<br />Brooks, OR 97305
<br />(505)393-089a
<br />Permit # 364
<br />medical wastes and that I have
<br />Data
<br />c.) Transferred containers, cu ft to : Brooks, OR C) c) Transferred containers, cu ft to : N. Sal Lake, UT
<br />ORIGINAL
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