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STANDARD MANIFEST 001.10-10 <br />:®• Sterlcycle' SE OF EMERGENCY CO CT: IIEMOTREC 1-810.234 1 M�FR��$ 5Hg <br />®• v,. v r. c Reauang RW Route 114 <br />€ 01214 6 4 <br />1. Generator's Name, Address and Telephone Numberloin <br />ATTN: Carla Vallem/Project1,2,2,111111111Nil <br />BIO/ST SOES IMMED CARE/OCCHLTH <br />1801 E. MARCH LANE BLDG 470D/480D <br />STOC7{TON, CA 95210 <br />(209) 467-6395 <br />7/8/2009 <br />6062804-'003 <br />CusToMER NumsER GENERATOR -s REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />REGULATED MEDICALf&UW.s.,6.2, <br />B802/Rs02 – 2 tial Sharps Reusable (0.3 Cu ft) <br />CONTAINERS <br />UN 3291, PG II <br />Cu FI <br />REGULATED MEDICALW&JO.s.,6.2, <br />BS03 RS03 – 3 Gal Sharps Reusable (0.4 Cu tt) <br />UN 3291, PG II <br />Cu FI <br />CC <br />REGULATED MEDICALjV6VE#V.s.,6.2, <br />6SOSIRS08 – 8 Gal ifiarps Reusable 41.1 Cu t <br />O <br />UN 3291, PG II <br />Cu FI <br />Q <br />REGULATED MEDICAL W.s.A.2, <br />eallft5rd– X1 WaX harps Reusdbtra' <br />UN 3291, PG II <br />Cu F1 <br />W <br />REGULATED MEDICAL WASTE,n.os.4.2, <br />TB02 – 150 Gal Reusable (17.4 cu t) <br />UN 3291, PG II <br />Cu Ft <br />tZ <br />REGULATED MEDICAL WASTE, n.D.s.,6.2, <br />UN 3291, PG II <br />Cu Ft <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />Rid <br />�' 3 <br />UN 3291, PG II <br />t •7•� t-=� ! 7� `� • C�{.l <br />Cu Fi <br />REGULATED MEDICAL WOAwBps.i6� <br />lCR65 – Wheeled Rack (59.4 Cu ft) <br />UN 3291, PG II <br />Cu R <br />Regulated Medical <br />KR S?C – Bio Systems Cart or Bax { cu it) <br />P <br />4-- <br />Cu F1 <br />3. Generator's Certificatkm: "I hereby declare that the contents of this consignment are fully and accurately EO,TAILS ® <br />`_ <br />-2— tP Cu Ft <br />described above by the proper shipping name, and are classified, packaged, mar and lalmliedtpiacarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations' <br />1 ` � <br />} <br />p <br />8 <br />Printed/Typed Name —Signature <br />Data <br />W <br />4. TRANSPORTER 1 ADDRESS: <br />Stericycle, Inc. <br />Phone #: (559) 7 – 0994 <br />Applicable Permit Numlrs: <br />a® <br /> <br /> <br /> <br /> <br /> waste asrived above., <br />iM1� <br />R� V . '?a'—e� <br />7 0 <br />PdntfT'ype Name Slgnature <br />Date <br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Phone # <br />`V <br />Applicable Permit Numbers: <br />15 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrintlType Name Signature <br />Date <br />vs <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />1:1515 <br />Applicable Permit Numbers: <br />Nd <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Z s <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION 1 . t® A 5u <br />Ke, G LIT <br />Trans" ! fS, CU to ry <br />8A. Designated Facility: 8B. Aitemete Facility.- ® 8C. Alternate Facility: <br />SD. Alternate Facility. <br />J <br />STERICYCLE INC STERICYCLE INC STERICYCLE INC <br />STERICYCLE INC <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />pit <br />TREATMENT FACILITY: I certify that'l silfAlitif3 plicable state agency to accept untreated medicsl wastes and that I have <br />h <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />Print/Type Namet <br />Date <br />€ 01214 6 4 <br />