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: • Stericycle`
<br />iN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424.9300 STANDARD MANIFEST 001.03.21•NOCA
<br />Route ;#: 703-10 CUSTOMER NO, 21132 MDTKO003HS
<br />1. Generator's Name, Address and Telephone Number Incinerate orShffr d Only
<br />ATTN: Maria
<br />!u !! II Iuu II
<br />SGMF STOCKTON MEDICAL PLAZA 1
<br />2505 W HAMMER LN
<br />11/22021
<br />STOCKTON, CA 95209-2839 (209) 422-7578
<br />6131468-001
<br />CUSTOMER NUMBER GENERATOWs REGISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />2B, CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />Regulated Medlcal Waste, n.m.,
<br />TB144BIo) TP14-(Path) TY144incinerate) 44 Gat. Tub
<br />5c$�u�yERS
<br />�)
<br />623291
<br />Cul
<br />UN3291Regulated Medical Waste, n,o,s„
<br />T8214810) 54PMh)TY154Chema) 20 Gal. Tub (2
<br />CuR.)
<br />----TPI
<br />Cul
<br />X
<br />8 23POII Regulated Medical Waste, n,o,s.,
<br />T84048Io) TY494Chemo)_T1494Incineratej 37 Gal. Tu
<br />(4.9 CUR.)
<br />CU I
<br />aUN32911I
<br />Regulated Medical Waste, n,o.s„
<br />WB434BIoj Ci*34Chemo �INX434Phan) 43 Gal. TU
<br />(5.7CuR
<br />Cu I
<br />W
<br />Z
<br />UN32911 Regulated Medical Waste, n,o.s„
<br />6.2, PGI]
<br />KR (Bio) Gal. Corrugated Box (4.32 Cult)
<br />cu I
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGIi
<br />Cul
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
<br />Cul
<br />UN3291 Regulated Medical Waste, n,o,s.,
<br />6,2, PGII
<br />Cu
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2. PGiI
<br />CU
<br />3, Generator's Certification: `I hereby declare that the contents of this consignment are fully and accurately TOTALS ►
<br />�2
<br />Cu f
<br />described above by the proper shipping name, and are classllled, packaged, marked and labelied/ptacarded, and
<br />are In all respects In proper condition for transport according to applicable International and national governmental regulations"
<br />Printed/ryped Name CA Signature
<br />f
<br />" Date ll
<br />4. TRANSPORTER 1 ADDRESS: I
<br />Phone M(209) 294-7114
<br />Stericycle, Inc. F1 This is a Through Shipment
<br />Applicable Permit Numbers:
<br />0
<br />7875 R A Bridgeford Rd.
<br />TS/OST-80
<br />1 a
<br />:N
<br />Stockton, CA 95206
<br />' Z
<br />TRANSPORTER C RTiFICTOI(IRIecelpiof medical waste as descrl e.
<br />�
<br />Print/rype Name Signature
<br />Date l
<br />6. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone M:
<br />Applicable Permit Numbers:
<br />s
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above,
<br />PrInV7ype Name Signature
<br />Dale
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone 0:
<br />Applicable Permit Numbers:
<br />w
<br />'
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />PrinMpe Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8r
<br />Faclll . (�^ Faellhy: SC,Altemate Facility:
<br />v
<br />8D,ANemats Faelltty:
<br />5
<br />Ste. (AutocCOAL Stericycle, no. (Incinerator) Stericycle, Inc. (Autoclave) Coval� Marion, Inc
<br />78gOord Rd, 40 N, Fox ro DNo 2775 E, 28th St,
<br />850 Brooklako Road NE
<br />Sto952** North Salt ake, UT a4054Vernon, CA 90066 Brooke, OR 97305
<br />02 1021
<br />EF_A.CILITY:
<br />(204 (8011}936- 171 (866)783-7422
<br />(505)393-0690
<br />•
<br />TST-00 3A -4481J -36 Perrrllt0 38x4
<br />tae
<br />TRTY: I ce Ifit fy #at I have be n authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the abovin es In accord nce with the requirement outlined in that authorization.
<br />PrinUlype Name Signature
<br />Date
<br />
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