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10 f--UlkAL I?VAZz ar. fNA.-.+5"ki Pn UN ids:d i.f2VIO C:'' <br /> � STANDARD MANIFEST 001-10-06-STD E OF EMERGENCY Ci�NT�AGT:Ct{EfUl1-EiEG 1-t00- 2.au-r��9 "C3 <br /> tAL III IFG CUSTG%„EP NO. <br /> ' <br /> .4 TRAtr tiTER:Stericyc�e I,u io a Number <br /> I <br /> 4135 A. Swift Ave <br /> Fresno, CA 93722 A <br /> (8ffi) 783-7422 <br /> For Stericycl G r Care <br /> Call 1 -783-7422 <br /> Stericycle Customer If 6121834 <br /> Site If 001 <br /> GP Canvas.Tattoo --- GENERATOFrs REGdsmxnoN# <br /> 304 N Harding Way CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> 2, Stockton, CA <br /> U TOW t, CONTAINERS <br /> 6 ROMf: (209) 981-01114 Cu Ft <br /> Contact : Nelissa Santos Cu Ft <br /> ,. <br /> G <br /> t SERVICE DATE: g/16/151 02:41 PN <br /> Cu Ft <br /> SHIPPINGf <br /> Hil.II �-- Cu--- Gu Ft <br /> LU <br /> Cu Ft <br /> 6.2, PGI I <br /> T Ear <br /> For DOT"T ,Response Cal I: Cu Ft <br /> DMECustomer No. 21132 Cu Ft <br /> TOTAL CONTAINERS : 1 <br /> TOTAL Ia : 5.900 CU FT Cu Ft <br /> VOL(Cott Type) t1TVEF Cu Ft <br /> T814 44 Pial Tub(BCo), CT 12.7 1 5 9W that the contents of this consignment are fully and accurately Cu Ft <br /> and are classified,packaged,marked and labelled/placarded,and <br /> 12 TB14 ort according to applicable international and national governmental regulations.' <br /> I hereby declare that the�ttents of this Signature Hate <br /> consignment are fully and accurately Phone r: <br /> a described above by the proper shipping Applicable Permit Numbers: <br /> -- <br /> name, and are classified, Packaged, marked <br /> e and labelled/placarded, and are in al l <br /> 13 <br /> rets in proper condition for transport <br /> o <br /> c s according to applicable international and eipt of medical waste as described above. ' <br /> L r national Bove tal regulations. <br /> $ Signature Date <br /> ® melissa san$os FR 2 ADDRESS: Phone,';: <br /> i <br /> Applicable Permit Numbers: <br /> ;b <br /> PORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Signature Date <br /> TER 3 ADDRESS: Phone# <br /> Applicable Permit Numbers: <br /> *PORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Generator Signature Signature Date <br /> Transporter Certification: Rodriguez, Clbr <br /> 8D.Alternate Facility: ®8C`.Alternate Facility: ❑BD.Alternate Facility: <br /> Transporter Signature It I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> Ll THIS ISA �I in accordance with the requirement outlined in that authorization. <br /> [K[LOCAL TM CWB <br /> Signature Date <br /> Ster icycle-Fresno,CA <br /> DESTINATION FACILITY: <br /> Incinerate Only <br /> Stericycle*rth Salt Lake,Ur <br /> 3A-448/JA-36 <br /> Dental 96.f. <br />