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StericycW
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 14800-424-9360 STANDARD MANIFEST 001•03.21•NOCA
<br />ROWC 1� 705-12 CUSTOMER NO, 2`1132 tvIDTK00053S
<br />C ag 9mr-AI MEN I FACILI I T: I been autnorized by the applicable state agency to accept untreated medical wastes and that I have
<br />r oven caled wastes In accordance with the requirement outlined In that authorization.
<br />PrInVType Name Signature Dale
<br />1. Generator's Name, Address and Telephone Number Incinel-ate or Shred Onl .
<br />ATTN: Marh
<br />t1K7aN MEDICAL PLAZA 1
<br />11111111111111111111111111SGMF STO
<br />[l� IE i IIS
<br />2505 W HAMMER LN 11/18/2021
<br />STOCKTON, CA 95209-2835 (209) 422-7573
<br />' G139�1f8-00�
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />29, CONTAINERTYPE
<br />2C, NO. OF
<br />20. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6,2, PGII
<br />TB 14 -(Lib) TP14-{Path) TY14-(Incinerate) 44 Cal. Tub
<br />r CONTAINERS
<br />��©CuR)
<br />Ct
<br />623 PGIIRepulaledMedlcalWaste, —nos,,
<br />TB21-(Bio)_ TP15-(Fath) TY15-(Chemo),_,-_ 20 Gal. Tub (`
<br />.7 Ct.Ift.)
<br />Ct
<br />0
<br />623291 Regulated MedlcalWastg,n.os'
<br />TB49- Bio TY49- Cherna T149- InGirierate 37 Gal. TL
<br />b 4,Q Cult.,
<br />CL
<br />UN3291 Regulated Medical Waste, n,o,s ,
<br />6.2,PGII
<br />r,
<br />V,1�43 (2ia} C11v13-(Chemo)_ WM43-(Phan'n) 4.3 Gal. TL
<br />b(5.7CLI9 1
<br />o ct
<br />Z
<br />623 PGIIRegulated Medical Wasle,n,os,
<br />KR (Blo) Gal. Corrugated Box (4.32 Cuft.)
<br />ILI
<br />Ct
<br />a
<br />UN3291 Regulated Medical Waste, n.o.s ,
<br />6.2, PGII
<br />Ct
<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 ► ct
<br />described above by the proper shipping name, and are classified, marked and labelled/placarclo and
<br />packaged,
<br />are In all respects In proper condition for transport according to applicable International and national governmental regu ons"
<br />/
<br />Printed/Typed Name Signature Data
<br />CC4.
<br />TRANSPORTER 1 ADDRESS; Phone N: (209) 294-71.14
<br />Stericycle, III
<br />� This is D Thl'ULIgh allll)IllCtlt Applicable Permit Numbers:
<br />a
<br />7875 R A Bridneford Rd. TS/OST-817
<br />- N
<br />Slocklon, CA 95206
<br />E a
<br />TRANSPORTER CERTIFICATION: \Receipt of medical waste as descr1 v0. Q p�,,,�
<br />�C�� l—&—e
<br />Printlrype Name �1 l�+L 11 Signature llilr n `'�"� Date At O
<br />5, INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone N:
<br />2
<br />Applicable Permit Numbers;
<br />2 i!5
<br />WINTERMEDIATE
<br />,
<br />HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone N;
<br />Applicable Permil Numbers:
<br />- � z
<br />n
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printfrype Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />WIAM r-1
<br />8A, Daalgn
<br />84. Alternate Facility:
<br />Incalk[FAe}
<br />BC. Aitamate Facility:
<br />8D, Altemsta Facility;
<br />riaycle,
<br />Ste ioycle, Inc. (incinerator)
<br />Stericycle, Inc. (Autoclave)
<br />Cavanta ivlarlon, Inc
<br />L
<br />7875 RA Lridpeford
<br />90 1. Foxboro Drive
<br />2775 E. 26th St,
<br />4550 Srooklake Road NE
<br />�
<br />Stea{iton, cNOW&��021
<br />No h Salt Lake, UT 8405x!
<br />Vernon, CA 00058
<br />Brooks, OR 97305
<br />&
<br />(209)294-7114
<br />(30 )936-1171
<br />(866)783-7422
<br />(505)393-0880
<br />TS(OS1:8 � c
<br />3A- I WA -3d
<br />Perinit 141 384
<br />C ag 9mr-AI MEN I FACILI I T: I been autnorized by the applicable state agency to accept untreated medical wastes and that I have
<br />r oven caled wastes In accordance with the requirement outlined In that authorization.
<br />PrInVType Name Signature Dale
<br />
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