|
�99,411111` Stericycle-
<br />IRmlecting People. Reducing Risk:
<br />9
<br />SERVICE R
<br />-T: CHEMTREC 1-800-424
<br />'t is MPEP11K 19213 2
<br />STANDARD MANIFEST 001-10-06-STDECEIPT
<br />MDFROOA-,EBX
<br />wnrim 11-
<br />sol9288-003
<br />]L -If SHIPPING 00cuMERT #: 0960AEBX
<br />j fj ?I j" _R
<br />.141 1 SMAN RD
<br />set; y"DIIJ 0111. MA& .0 ribil
<br />i %atn ivi atui ,, evaine, mucuress ana ie - Pacific Medical
<br />ATTN.- Wr j. SERVICEVER DATE10: 1/11111 11:07:41 i
<br />DRI: RJF
<br />BAi�-'XFJCC M&I11CAL
<br />]L -If SHIPPING 00cuMERT #: 0960AEBX
<br />j fj ?I j" _R
<br />.141 1 SMAN RD
<br />set; y"DIIJ 0111. MA& .0 ribil
<br />TRACY, (7A 95304 TOTAL COLLECTED: 6
<br />TOTAL WLUME: 29.000 CU I'l
<br />V3.1'111'2013
<br />OOAOOR9TB14 AV';,-tPre
<br />(j-, 00AWK TB14 OOAOOR3 TB15 1111A.1.46 TO!*,
<br />CUSTOMER NUMBER (5019MB-0 =-GisrRATioN #
<br />2A. DESCRIPTION OF WASTE 2B. VOL
<br />2C. NO. OF 2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s., S~(Cont Type) QTY CF
<br />CONTAINERS
<br />6.2, PGII TB -57
<br />TOM 44 Cal Tub(aio), CT 12.1 4 23,6011
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGI[ T64 9 T915 20 Gal Tub(Path), ET 5.7 2 5.410
<br />Cu Ft.
<br />CC
<br />UN3291, Regulated Medical Waste, n.o.s.,'
<br />6.2, PGII `L014 - -9 %7u lx;
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TB21 - 10 Gal Tub (Bt0 (2.7 CU ft
<br />6.2, PGII
<br />Cu Ft.
<br />W
<br />Z
<br />UN3291, Regulated Medical Waste. n.o.s.,
<br />6.2, PGII
<br />TB15 - 20 G -al Tub (Patll) 42.7 cu Ift)
<br />Cu Ft.
<br />U.1
<br />UN3291, Regulated Medical Waste'r.D.S.,
<br />6.2 , PGII
<br />IrY-t 5 -- 20 G-31 Tith (Chemo) (27 . -,u ft)
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />Rhamag-eutic I
<br />Cu Ft.
<br />TOTA3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately LS 101,
<br />1 Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects In proper condition for transport according to applicable international and national governmental regulations.'
<br />xPrintecirryped Name Signature
<br />Date
<br />Ir
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone #: (5 15 9 0
<br />W
<br />Steric-yc-le, ink,
<br />Applicable Permit Numbers:
<br />r 6i
<br />0
<br />4136 Ofe3t Swift*Ave.
<br />EI/Ttits 3:3 a Vi'roUgli Shipment
<br />U)
<br />f <Z
<br />Zvesno, C. 93722
<br />TRANSPORTERCERTIFICATION: Receipt of medical waste as desc a.,(*e-
<br />J—f
<br />7
<br />— C ,
<br />VI
<br />f
<br />Date
<br />I
<br />Print/Type Name - Signature
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: V
<br />Phone #:
<br />luj
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />M
<br />Srz
<br />Print/Type Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />:2 W
<br />1 z
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receiptof medical waste as described above.
<br />,,0
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Z -A d qcu ft to' Nonh Saft Lake, UT
<br />Tr
<br />j 8C. Alternate Facir
<br />8A. Designated Facility: 8B. Alternate Facility:ity:
<br />8D. Alternate Facility:
<br />9
<br />Stericycle inc-Autriclave Ste"cle ino- Indnerlation Stericycle Inc -Autodave
<br />Stericyde Inc -At d®ve
<br />4136 W. SWIFT AVE 90 NORTH I I W VEST 1345 DooMe Drive Ste C
<br />2775 E 26TH STREET
<br />L. 22
<br />FRESNOCA 93722 NORTH SALT LAKE CITY, UT earl Leandro, CA 24577
<br />VERNON,NION, CA SM23
<br />(652) 276 -w 0294 (001) 936 - 1666 (510) 662- 1781
<br />(323) 362 - 3000
<br />U .9nerabon
<br />TS- 3 1, TWOST2" TSIOST22 Cla-Sav IndPernU 9102
<br />P- 1115
<br />U HTREATMENT
<br />FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print(Type Nage Signature
<br />Date
<br />
|