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<br />5tericycle°
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1800-4249300 STANDARD MANIFEST 001•03.21•NoCA
<br />Roule 4. 703 -24 CUSTOMER NO. 21132 MDTK0004TN
<br />1, Generator's Name, Address and Telephone Number Incinerate oI-Shred Only
<br />� I PrinMpe Name Signature Date
<br />ATTR: Maria!1 i��ll�llI I I�
<br />i! �I�III1 IIS1� �I
<br />SGiv1F STaGKTON MEDICAL PLAZA 1
<br />2505 W HAMMER LN
<br />'11/16/2021
<br />STOCKTON, CA 552130-2839 (209) 422-7578
<br />6131468-001
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO, OF
<br />20, VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />TBI TP1d-(Path) TY14-(Incinerate) 44 Gal, Tub
<br />C NTAINERS
<br />5.3Cuft)
<br />6.2,FGIf
<br />Cu
<br />UN3291
<br />23 PGII Regulated Medical Waste,
<br />T1321 -(Bio), TP15-(Path) TY15-(Chemo)^•_, 20 Gal. Tub ('
<br />.7 Cult.)
<br />_
<br />Cu
<br />CC
<br />62329i Regulated Medical Wastp,, n.o.s.,
<br />TB49-(Bio)^_TY40-(Chemo)_ 3140-(Intinerate) 37 Gal. T
<br />b (4.0 Cuft,
<br />Cu
<br />623 PGII Regulated tdedlcatWaste, n.os,
<br />X43 (BiD) �IVX4?-(Pharr(,) 43 Cal. TL
<br />b (5.7Cuf
<br />�1
<br />217.
<br />_C�hr43-(Chemo)
<br />Cu
<br />W
<br />Z
<br />UN3291 Regulated Medical Waste, n.e.s„
<br />6.2, PGII
<br />KRBIG. Corrugated BOX 4.32 Clift.
<br />( ) CalCo0- ( )
<br />Cu
<br />Lu
<br />()
<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 />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 110 -,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 national governmental reg ations"
<br />ped Nae % C Signature
<br />Print m
<br />%
<br />1
<br />Date �
<br />4. TRANSPORTER 1 ADDRESS; k
<br />Inc.
<br />Phone #: (209) 294.71114
<br />hstelicycle,
<br />This iS i Through Shipment
<br />Applicable Permit Numbers:
<br />7375 R A Brit:l0eford Rd.CC
<br />T 1 7`• I -8D
<br />a N
<br />Stocklon, CA 55206
<br />L Z
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as dewibed_sUve,
<br />j
<br />k� Glid% tri �—"`�—
<br />+ 1
<br />PrinUiypeName Signature .—Date_
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />j1Applicable
<br />Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinuType Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />g
<br />Applicable Permit Numbers:
<br />t�
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />—
<br />Prtnt%pe Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />9
<br />_� + I C
<br />SA. Deeignat"Ryjkl�Q
<br />tericycle, Infrcll,ii(c'�vA
<br />BB.
<br />Steri
<br />Namata Feclllry; �] 8C. Alternate Facility;
<br />Inc.
<br />80. ANemate Facility:
<br />875 RA Bridge
<br />90 N
<br />.ycle, (Incinerator) Stericycle, Inc. (Autoclave)
<br />Foxboro
<br />Co%/anta Marion, Inc
<br />t
<br />Drive 2775 E. 26th St,
<br />4850 Brooklake Road NE
<br />Stockton, G 5204
<br />Nortl
<br />Salt Lake, UT 840511 Vernon, CA 00068
<br />Brooks, OR 07306
<br />209)294-' IKOV 16
<br />(401
<br />935-1171 (866)783-7422
<br />(545)393-0890
<br />E g
<br />S
<br />I SADS —1-80
<br />3A-4
<br />I BIJA-36
<br />PeFirlttil 364
<br />8g
<br />T EATMENT'FACI-A'f' gI&% that
<br />I have
<br />been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />r e above Indicated wastes in
<br />accD
<br />dance with the requirement outlined In that authorization.
<br />� I PrinMpe Name Signature Date
<br />
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