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�i Stericycle` 1N CASE OF EMERGENCY CONTACT: CHEMTREC 1.600-424-93110 STANDARD MANIFEST 001.03.21-NOCA
<br />ROule # 705 -12 CUSTOMER N0.21132 MDTKO003RQ
<br />1. Generator's Name. Address and Teleohone Number
<br />ATTN: Dwain Baughman ��� Ililliliiliilllllllllllilillllliflllil11111111
<br />Ill
<br />RXW/` GMF MEDICAL PLAZA 1
<br />2505 W HAMMER LN
<br />11/4/2021
<br />STOCKTON, CA 95209-2839 (209) 521-6097
<br />6131462-750
<br />CUSTOMER NUMBeR GENERATOR'S REGISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINERTYPE
<br />2C, NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o,s„CONTAINERS
<br />ISRR2-(Pliarrn) 2 Shelf Wheeled Flack (48 CLlft.)
<br />6.2, PGII
<br />Cu I
<br />UN3 91 Regulated MedlcalWaste,n.o.s.,
<br />KRR3-(Phan-n) 3 ShelfN/Vheeled Rack (62 Cuft.)
<br />Cul
<br />CC
<br />UUN322911 Regulated Medical waste,n.o.s.,
<br />6.2, PGIICul
<br />RX-(Pharm)_"Gal. Con'Llgated Box (4.32 CLI
<br />UN3PGII Regulated Medical Waste, n.o,s„
<br />R X-(Pharrn) Gal. Corrugated Box (4 ,32 Cult.)
<br />Cu 1
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />IZ
<br />6.2, PGII
<br />• Cu I
<br />RULI
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />"u Q t
<br />Cu I
<br />UN3291 Regulated Medical Waste, mo,s.,
<br />6.2, PGIIRUI
<br />t i u a
<br />Cu I
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu I
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />CU 1
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 1110-
<br />AI,Al Cu I
<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 regul ns"
<br />Printed/T ped NameSignature
<br />Date
<br />4. TRANSPORTER 1 ADDRESS:
<br />Stericycle, Inc.
<br />Phone (• 09) 294-7114
<br />This is a Through shipment
<br />Applicable Permit Numbers:
<br />c
<br />7875 R A Bridgeford Rd.
<br />TS/OST-30
<br />Stockton, t;A 95206
<br />L Q
<br />TRANSPORTER CERTIFICA Receipt of medical waste as describe ove.
<br />PdnVType Name Signature t tq
<br />Date Q7 FLV
<br />6. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />Phone N:
<br />j
<br />Applicable Permit Numbers:
<br />i
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinVType Name Signature
<br />Dale
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone N:
<br />Applicable Permit Numbers:
<br />2
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />PrinUTypa Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />89, Anemate Faclllty: 8C. ARamate Facility:
<br />11D.'Alternate Facllfty:
<br />i
<br />„
<br />e, Inc,'i�,S erl c ,Inc. (Inclnlaratar) terioyole, Inc. (Autoclave)
<br />'' O'
<br />ovanta Marion, Inc
<br />orpl 0 N. F xbaro Drive 775 E. 26th St,
<br />650 EirooJJake Road NE
<br />-
<br />11
<br />, CA 952Q EA Jordi S It lake, UT 64064 t ernon, CA 90058
<br />rooks, OR 97305
<br />T9)294 -71`14
<br />��V'' IB01)9 -1171 86)783-7422
<br />60 OZ� A-446
<br />Q5)303.0000
<br />JA -36
<br />ermit# 364
<br />pt
<br />MEN I Ify that I have een authorized by the applicable state agency to accept untreated
<br />medical wastes and that I have
<br />the��tes In acco dance with the requirement outlined in that authorization.
<br />PrinMpe Name Signature
<br />Date
<br />
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