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i i� Steric�/CIe� IN CASE OF ErEj?ENC}� CQNTPCT: CHEMTREC 1-800-4249300 STANDARD MANIFEST 001.03.21•NOCA
<br />• J �QLi fF. ! U3 -�F CUSTOMER N0.21132 iViDTE 000511
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<br />SGMF STOCKTON MEDICAL PLAZA 1
<br />I IIS
<br />2505IJU HAMMER LN
<br />11/23/2021
<br />STOCKTON, CA 95209-2839 (209) 422-757"0
<br />6131468-001
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION p
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />Regulated MedicalWasle,n,o.s.,
<br />TB'14-(810)^_T1�1rI-(�Dth) 1Y1d-(Incine►-ate) d4 Coal. Tub
<br />�gjNUTd�1Rs
<br />6.23291
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<br />UN3291
<br />11I Regulated Medical Waste, n.o.s.,
<br />T821 -(Bio )__ 7P'15-(Patii)__TY15-(Chemo )___,•_„- 20 Gaal. Tub (:.7
<br />Cuff.)
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<br />UN3291 RegulaledMedical Wastp,n.os.,
<br />TBJQ-(Bio)J_TY49-(ChE?rno)_�T149-(Indrrprate) 37 Gal. Trb(4.9Cuft.;
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<br />Regulated Medical Waste, n.os.,
<br />k%VB43-(BiO) C'drtlj$-(CheY+10)_ 4vX43-(Phatrrl) 43Gaa1.TLb(5.7Cuf
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<br />UN3291 Regulated Medlcal Waste, n.o.s„
<br />6.2, PGII
<br />KR ,(8iu) Gal. Cornagated Box (4.32 Cuft.)
<br />Cu
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
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<br />UN3291 Regulated Medical Waste, n.o.s„
<br />62, PGII
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
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<br />UN3291 Regulated Medical Waste, R.O.s„
<br />6.2, PGII
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS /
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<br />described above by the proper shipping name, and are classfNed, packaged, marked and labelled/placarded, and
<br />are in all respects In proper condition for transport according to applicable International and national governmental re atlons:'
<br />PrIntedrryped Name tmaC Signature lM Date
<br />4. TRANSPQQRTER 1 ADDRESS:
<br />�It?IIcycle, Ilie. Tills Is a Thl-CILlgh L hipifieni
<br />Phone k: ( y J= - '14
<br />Applicable Permit Numbers:
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<br />7"075 R A E71idgeford Rd.
<br />TS/OST-80
<br />Stockton, CA 95206
<br />CL a
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as describe ve,
<br />�V�� �,-.A �+""` ��
<br />PrintrypeName - Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS:
<br />Phone b;
<br />V
<br />5
<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 HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone If:
<br />Applicable Permit Numbers;
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />d�=
<br />—
<br />PrInVType Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
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<br />3
<br />Alternate Facility: 8C, Alternate Facility:
<br />�tericycle, ,a/��t I�E Ste icycle, Inc. (Incinerator) Stericycle, Inc. (Autoclave)
<br />E] 8D, Alternate Facility:
<br />C:ovanta m2rion, Inc
<br />,I
<br />76'75 PA DridjhrteA 90 f I. Foxboro Drive 2775 E. 2601 St,
<br />4850 Drooklake Road NE
<br />S tooklon, GA 6 C Nor h .salt Lace, UT 84054 Vernon, CA 00058
<br />Brooks, CR 97305
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<br />(209)294-7�4 (80 )938.1171 (866)783-7422
<br />TS1GS7817 r r V 23 1021 5A 16/JA 30Prin,ltrr<
<br />(505)393-0800 .
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<br />38a
<br />REATMEN that I hav been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />celved the�awastes In acc rdance with the requirement outlined In that authorization,
<br />r nVType Name Signature
<br />Date
<br />
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