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<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.600-424.9300 STANDARD MANIFEST 001.03.21-NOCA
<br />Route M 705 -13 CUSTOMER No, 21132 MDTKO003RR
<br />Add a ATele hone Number Incinerate pr"hrPd Onl
<br />Print/Type Name
<br />Signature
<br />Date
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<br />:GMF 13TOCKTON MEDICAL_ PLAZA I 111
<br />2505 W HAMMER LN
<br />11/4/2021
<br />STOCKTON, CA 05209-2530 (209) 422-7570
<br />r
<br />6131468-001
<br />CUSTOMER NUMBER GENERATOR'S REaIeTRA110N N
<br />2A• DESCRIPTION OF WASTE
<br />2B, CONTAINER TYPE
<br />2C, NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Wasle, n,o.s„
<br />6.2, PGII
<br />T814-(Bio)TP14-(Path) TY14-(Inoir,eratp) 44 Cal, tib (�
<br />CON INERS
<br />,nCu
<br />Cu
<br />62, PGII Regulated Medical Waste, n.os.,
<br />TB21-(Bio)_ TP15-(Path)_ TY16Chemo)__ 20 Gat. Tub (2.
<br />CLift,)
<br />Cu
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<br />62,PG11IRegulated Medical Waste, n.os.,
<br />TB40-(Bio) TY49-(Chemo)_ T14O-(Incinerate) 37 Gal. Tub
<br />(4.9 Cuft.)
<br />Cu
<br />U232911IRegulated Medical Waste, n,o,s,WB43-(Bio)
<br />CW113-(Chemo)_ iNX4?-(Phatrn) 43 Gal. Tub(5.7Cuft.
<br />Cu
<br />W
<br />Z
<br />UN3291 Regulated Medical Waste, %0.s.,
<br />6.2, PGII
<br />kR (i3io) Gal. Corrugated Bax (4.32 Cuff.)
<br />Cu
<br />LLI
<br />6 23291 Regulated Medical Waste, n,o.s.,
<br />Cu
<br />UN3291 Regulated Medical Waste, n,o.s.,IL
<br />6.2, PGII
<br />, 1 ti'
<br />Cu
<br />UN3291 Regulated Medical Wasle, n,o,s„
<br />6.2, PGII -
<br />!
<br />Cu
<br />UN3291, Regulated Madical Waste, n.o.s.,
<br />6.2, PGII
<br />C
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately 70TALS
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<br />described above by the proper shlpping name, and are classified, packaged, marked and labelled/place—ed, and
<br />are In all respects In proper condition for transport according to applicable International and national governmental regule
<br />Printed/T eV Neme C P SI nature
<br />+^ Data l�
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<br />4, TRANSPORTER 1 ADDRESS;
<br />Stedcycle, Inc. This is D Through Shipment
<br />Phone t(;209) 294-7114
<br />Applicable Permit Numbers;
<br />7878 R A Bddgeford Rd. ;
<br />TS/OST-80
<br />E °
<br />Stockton, CA 95206 `
<br />L
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as describe bove
<br />pa
<br />~
<br />7 ati. I,, �L
<br />PrinMpe Name W Signature 2 F�
<br />Date
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone N:
<br />Applicable Permit Numbers:
<br />!
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature
<br />Dale
<br />6, INTERMEDIATE HANDLER 3l TRANSPORTER 3 ADDRESS:
<br />Phone N:
<br />Applicable Permit Numbers:
<br />a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />x
<br />—
<br />PrinVType Name Signature
<br />Date
<br />�-
<br />T. DISCREPANCY INDICATION
<br />Lj 8B, Attamate Facllltyi El 8C. Alternate Facllttyt
<br />8D. Akamate Facility:
<br />t ricycle, l lave)
<br />Stericyole, Inc. (Incinerator) • tedoycle, Inc. (Autoclave) t ovanta Marion, Inc
<br />2
<br />875 RHE
<br />0 N. Foxboro Detre 1776 E. 26th St,
<br />�1 rel LVE
<br />tocidon, CA 95205
<br />lorth Salt Lake, UT 84054 `rernon, CA 99058
<br />209)294 f� Q ;Li)z)
<br />01)996-1171 (66)783-742206
<br />93-0 99
<br />5f437 80
<br />A �1481JA-s6
<br />err3 8
<br />TREAT certify that
<br />I have been authorized by the applicable state agency to accept untreated me&4 and that I have
<br />received the above Indicated wastes It
<br />accordance with the requirement outlined in that authorization,
<br />(503) ,
<br />Print/Type Name
<br />Signature
<br />Date
<br />
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