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s.;. Stericycie
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.100-�24-fl3110 STANDARD MANIFEST 001-03.21•NOCA
<br />Route # 253 -2 CUSTOMER NO. 21132 MDTK00052Y
<br />1. Generator's Name, Address and Telephone Number Incinerate or Shred On
<br />ATTN: Maria III Illllllllllliil Il I I III NBilllBIIIII IBI 1111 III
<br />SGMF STOCKTON MEDICAL PLAZA 1
<br />2505 W HAMMER LN 11130/2021
<br />STOCKTON, CA 95209-2839 (209) 422-7578
<br />6131468-nni
<br />CusTomm Nu►teeR
<br />2A. DESCRIPTfON OF WASTE
<br />UN3291,, Regulated Medical Waste, n.o.s.
<br />UN3291
<br />6,2, PGII
<br />n,o,s.,
<br />CC
<br />O
<br />UNJZ91 N6gUlatea MealOal waste, n.0.e.,
<br />6,2, PGII
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />T021481o)
<br />LLI
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />6.2, PGII
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />T1494Incinerate} 37 Gal.
<br />6,2, PGII
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />8.2, PGII
<br />KR__ _.__(Bio)
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291 Regulated Medical Waste, n.o,s„
<br />8,2, PGII
<br />QaNLRATOR'a RaOIaTIRATION N
<br />TB14{BI6)
<br />TP14-(Path)
<br />TY 144Incinerate} 44 Gal. Ti
<br />T021481o)
<br />TP15-(Path)
<br />TY154Chemo) 20 Gal. Tub
<br />TB494Bb)
<br />TY49-(Chemo)
<br />T1494Incinerate} 37 Gal.
<br />VAB434Blo)_S__CW434Chemo)
<br />WX43-(Pharm) 43 Gal.
<br />KR__ _.__(Bio)
<br />Gal. Cornmated Box (4.32 Cuff.)
<br />2C, NO, OF 211).
<br />CONTAINERS
<br />(5.9CuR)
<br />.7 Cull.)
<br />b (4.9 Cuk.
<br />b (5.7Cuft.
<br />VOLUME
<br />....,..... A 1
<br />3. GermMoes Ceriff elon: "I hereby declare that the oontents of this oonslgnrrient are fully and accurately LTOTALS 11111- I 3 !V 4 Cu i
<br />described above by the proper shipping name, and are dasOW, packaged, marded and labelled/plecarded, and
<br />are In all respects in proper condition for transport according to applicable international and national governmental regulations'
<br />11�3(3�L1
<br />Name re DoW
<br />4. TRANSPORTER 1 ADDRESS: Phones: )294-7114
<br />Stericycle, Inc. This is a ThroUgh Shipment Applicable Permit Numbers:
<br />7875 R A Bridgeford Rd. TS/OST-80
<br />Stockton, CA 95206
<br />L
<br />TRANSPORTER ATiO Ipt of medical waste as described
<br />PrInVType Name �../ Slgnstur Date
<br />a. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone 0:
<br />• Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Reoeipt of medical waste as descrlbed above,
<br />Print/Type Name Signature Data
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS; Phone M:
<br />Applicable Permlt Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />• L ` r 60. hernate, Facility: aC. Albmab Facility: aD. Atbmst• Foci My:
<br />terl�yOle, 1 e. e Ste ycle, Inc. (Incinerator) Stericycle, Inc. (Autoclave) Covanta Marion, Inc
<br />876 RA Bddg 90 Foxboro DrN* 2776 E, 26th St, 4860 Bmoklake Road NE
<br />tockton, CA M206 t Nort 1 Salt Lake, UT 94054 Vernon, CA 90058 Brooks, OR 97305
<br />V 0 2021
<br />j
<br />209)294-71 3 (801 936-1171 (866)183-7422 (505)393-0890
<br />80 3A BIJA-36 Permit* 364
<br />PS/OST
<br />EATMENVI that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />r slued the above indicated wastes In acro once with the requirement outlined In that authorization.
<br />PdnVlype Name Signature Date
<br />....,..... A 1
<br />
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