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0-eo Stericyclem IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.BOG-424.93DO STANDARD MANIFEST 001-03-21-NOCA
<br />Rattle #. 704-4 CUSTOMER NO. 211132 MGTK000EJ0F
<br />1 r;anarntnr'c Namp_ Arlrlraca aniTplpnhone Number Inninar Fn —Ok—I (lulu
<br />Al'TiJ: Maika
<br />�II ��A�lll�f�l� � �i�illl �1 �
<br />���PJIF �Tc�rI:T01v MEDICAL PLAZA '1
<br />KTO I� 1����
<br />2.505 VV HAMMER LN 11/24/2021
<br />STOCKTON, CA 95209-2539 (209) 422-7578
<br />6131463-001
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION N
<br />2A, DESCRIPTION OF WASTE
<br />213. CONTAINER TYPE
<br />2C. NO. OF
<br />21). VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />6.2, PGII
<br />TS 1d -(Bin) TPl4-(Pani) TY14-(Incinerate) 44 Gal. Tub
<br />CONTAINERS
<br />'S.�3Cuft)
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<br />Regulated Medical Waste, n.e.s„
<br />6.2, poll
<br />6.2, PGII
<br />TB2-1- Bio I P15- Path TY 15- Cherno 20 Gal. Tui, 9
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<br />7 Cuff.
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<br />62,PG1IIRegulated Medical Wastt3,n.o.s„
<br />TB40-(Bio)_,_„•TY1E-(Cllel;io) Tit10-(Incinerate) 37 Gal. T1.
<br />b (4.0 Cuft.'
<br />Cu
<br />UN3291 Regulated Medical Waste, n.o.s.,,
<br />6.2, PGII
<br />W8131 -(Bio) CV11.1',-(Cherno) VVX4 a-(PhalTn) 43 Coal. Tl
<br />b (5.7GU{+1)
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />ISR (Bio) �.-Gal. Corrugated Box (4.'32 Cuft,j
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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, n,o.s.,
<br />6,2, PGII
<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 />6.2, PGII
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<br />3. Generator's Certification; "I hereby declare that the contents of this consignment are fully and accuratelyy TOTALS 1111-I I• a 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 regu Ions:'
<br />Prints ped Name C Signature Date �r 2
<br />4. TRANSPORTER 1 ADDRESS: Phone A: (20 9) 294-79'111.
<br />Stericycle,111C, This is a Through Shipment Applicable Permit Numbers:
<br />x
<br />7075 R A Bridgeford Rd. T S/0 � T-00
<br />f y
<br />Slocklon, CA 95206
<br />E a
<br />TRANSPORTER CERTIFICAZI: Receipt of medical waste as descrl'Le�-ayove. 1
<br />r�/�f�
<br />PrInnpe Name t Signature �� Date
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone N;
<br />SApplicable
<br />Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature Date
<br />1$
<br />6, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone N:
<br />1
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above,
<br />I�x
<br />c
<br />—
<br />Print/Type Name Signature Date
<br />7, DISCREPANCY INDICATION
<br />. Alternate Facility: 6C. Alternate Facility: BD. Attemate Facllity:
<br />�BA. DeslpUSE
<br />`
<br />j 2
<br />tericyole, Inr i Ve) St ricyCle, Inc. (Incinerator) StEricycle, Inc. (Autar;lave) Covanta f1arion, Inc
<br />7875 RA Bri1�AV. 9C N. Foxboro Drive 2776 E. 26th St, 4850 BrooNake Road NE
<br />Stockton, �j o5 IV rdi Salt Lake, LIT 84054 Vernon, CA 90058 Brooks, OR 97305
<br />�'2)
<br />E
<br />(20�J)294- � R1 1 838-1177
<br />]' � ( ) (866)782-7422 (505)S92-0990
<br />U
<br />E q
<br />Si9n
<br />TS/09T-80 3P F119/JA-90 Fermit# 801
<br />TREATMENI'ff(:iLiYYify that I ha a been authorized by the applicable slate agency to accept untreated medical wastes and that I have
<br />-
<br />re ordance with the requirement outlined In that authorization.
<br />Print/Type Name Signature Date
<br />
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