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` 1N CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.424-8300 STANDARD MANIFEST
<br />Stericycle
<br />Route # 703 -11 CUSTOMER No. 21132 MDTK00045L
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<br />ATTN: Melia
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<br />SGMF STOCKTON MEDICAL PLAZA 1
<br />2505 W HAMMER LN
<br />11/912021
<br />STOCKTON, CA 95209-2839 (209) 422-7578
<br />6131466-001
<br />CUSTOMER NUMNER GENERATOR's REOIsTRAT1oN N
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />21). VOLUME
<br />.,
<br />UN329t Regulated Medical Waste, n.o.s6.2, PGII
<br />Tg14 //810 TP14- Path TY14 InGitlerate 44 Gal. Tub
<br />cop4TAINERS
<br />ACuf
<br />UN3291
<br />23PGII Regulated Medical Waste, n.o.s.,
<br />TB21-(Bio) TPi 5 (path) TY15 +iChetno} 20 Gal. Tub (2.
<br />CuR.)
<br />Cu
<br />CC
<br />B 23PGII Regulated Medical Waste, n.o.s„
<br />T134948b) TY494Chemo) T149-(Indnerate) 37 Gal. Tub
<br />(4.9 CuR.)
<br />Cu
<br />Q
<br />UN3291
<br />23PGII Regulated Medical Waste, n,o.s.,
<br />M3{Blo)ACVA3-(Chemo) M43-(Phann) 43 Gal. Tub
<br />(5.7Cutt.
<br />fx
<br />,
<br />Cu
<br />W
<br />UN3291 Regulated Medical Waste, n.os„
<br />6.2, P0311
<br />KR (Blo) Gal. Corrugated Box (4.32 CUA.)
<br />Cu
<br />tZ
<br />UN3291 Regulated Medical Waste, n,os„
<br />6.2, 1`0 11
<br />Cu
<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 />I
<br />Cu
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGI]
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ►
<br />22,
<br />cu
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are In all respects In proper condltlon for transport according to applicable International and national governmental reg I lions,"
<br />Ct
<br />Printedlryped Name Signature
<br />Date
<br />4, TRANSPORTER i ADDRESS:
<br />Phone (209) 294-7114
<br />UJ
<br />Stericycle, Inc. F-1Thisis a Through Shipment
<br />Applicable Permit Numbers:
<br />7875 R A Bridgeford Rd.
<br />TSMT 80
<br />E N
<br />Stockton, CA 95206
<br />L Z
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as descrf
<br />�
<br />~
<br />PrinUType Name �^ Signature (^►�'+ f
<br />Dale 111091001
<br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />Phone N:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature
<br />Date
<br />6, INTERMEDIATE HANDIER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone N:
<br />Applicable Permit Numbers:
<br />J
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />x
<br />PrinUrype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />BB, Ahemate Facility: El ac, Alternate Facility:
<br />8D. Alternate Facility:
<br />I
<br />to lCycI Y(Aoolav9) tarlcyale, Inc. (Incinerator) Vericycle, Inc. (Autoclave)
<br />ovantei Marlon, Inc
<br />f
<br />876pF
<br />�W. 0 N. Foxboro Olive 776 E. 26th St,
<br />860 8rooklake Road NE
<br />A
<br />toc}Wn, orth Salt Lake, UT 84054 lemon, CA 90058 Brooks,
<br />OR 97305
<br />209)2�1� JC1 801)936-1171 66)783-7422 05)393-0890
<br />$
<br />S/OST 80 A-448/JA-36
<br />ermlt# 364
<br />TR�NT�1 C,,�L,,JI Y: I certify t at I have been authorized by the applicable slate agency to accept untreated
<br />receiv'�`d&W"aced wast In accordance Wlth the requirement outlined In that authorizatlon.
<br />medical wastes and that I have
<br />PrinVTypa Name Signature
<br />Dale
<br />
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