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9.-.9 StericycW IN CASE OF EMERGENCY CONTACT: CHEMTREC 1•SDO-424-9300 STANDARD MANIFEST 001.03.21•NOCA
<br />ROL1te #. 705-12 CUSTOMER NO. 21132 IlADTI00004ET
<br />1. Generator's Name, Address and Telephone Number Incinerate or Shred Only
<br />ATTN: WiriaIlf III�IIi�lllll�I lI I II lIl
<br />illlllllllll I II II III II IA
<br />SGMF STOCKTON MEDICA1.. PI -.ASA 1
<br />25051N HAMMER !_N
<br />11/11/2021
<br />STOCKTON, CA 95209-2839 (289) 422-7578
<br />6131468-001
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />2e. CONTAINER TYPE
<br />2C, NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6,2, PGII
<br />F
<br />TB14-(Bio) TP14-(Path) TY14-(Incinerate) 44 Cal. Tub (�
<br />CONT INERS
<br />9cuft)
<br />Cu
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />TB21-(Bio) TP15-(Path)_____TY15 (Cliet7to)______20 Gal. T1.tb (2.,
<br />Cuft.)
<br />Cu
<br />X
<br />623 PGIIRegulaledMedlcalWaste,n.c.s„
<br />TB4Q-(Bio) TY4Q-(CherrlD)_ T14Q-(Incinerate) 37 Gal. Tub
<br />(4,DCL1ft.)
<br />Cu
<br />�
<br />PGIIRegulated Medical Waste, n.o.s.,
<br />a3 (gl0)GVV13-(Chemo)_ WX43-(Phat�tij 43 Gal. Tub
<br />(MCuft.`
<br />623
<br />Cu
<br />W
<br />UN3291 Regulated Medlcai Waste, n.o.s.,
<br />6.2,PGII
<br />KR (BID) Cal. Corn-igaied SOX (4.32 Cuft.)
<br />Cu
<br />IZ
<br />UN3291 1I Regulated Medical Waste, n.o.s,,
<br />Cu
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu
<br />UN3281 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Gu
<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 0-
<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 condition for transport according to applicable international and nationat governmental r Ions"
<br />Prints ped Name &aaonC` ' v v Signature
<br />0001,
<br />Data Ohl
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone (209) 294-T-114
<br />Stdticycle, I11c. F� This IS 9 T11rOt.1,11 Shit?iileilt
<br />Applicable Permit Numbers:
<br />7875 R A Oridgeford Rd.
<br />TS/0STT80
<br />2 0.
<br />Stockton, OA 95206
<br />y a
<br />TRANSPORTER C' �yA,T.IFICAT11ON: Receipt of medical waste as describZ:ve..PrInUType
<br />Name 1��Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TPANSPORTER 2 ADDRESS:
<br />Phone #:
<br />iApplicable
<br />Permit Numbers:
<br />NINTERMEDIATE
<br />t
<br />HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinilTMpe Name Signature
<br />Date
<br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />f ¢
<br />Applicable Permit Numbers:
<br />i�
<br />I �
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />—
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />noted Facility: 89, Aftemete Facility: 8C. Alternate Facility:
<br />RD. Alternate Facility:
<br />s
<br />C
<br />ter cycle, Inc. ( 1� �15'� terleyel , Inc, (Incinerator) tericycle, Inc. (Autoclave) .ovanta Marion, Inc
<br />87 RA BridgeFDrr ��EA 0 N, Fc bore Drive 775 E. 28th St,
<br />to Ian, GA 95208 otth S It Lake, UT 84054 'rernon, GA 90058
<br />850 BroolJoke Road NE
<br />rcoics, 97305
<br />3
<br />�yg
<br />20 )294-7114 N�� 1.221 801)93 -1171 188t3)783-7422
<br />05)393-0890
<br />S/ ST30 A -4413/A-30
<br />Frn*#304
<br />S
<br />T ATMENT F.pjCILIYy; I ce ify that I have een authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />thea In
<br />re slued es accor once with the requirement outlined in that authorization.
<br />PrinUType Name -- Signature
<br />Data
<br />
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