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5tericycle` IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.424.9300 STANDARD MANIFEST 001-03-21•NOCA
<br />a RGUIe 4f 705 -11 CUSTOMER NO. 21132 AAD1 K0004ES
<br />I -in_s.,e.ai.,.+a Ammo Aritlrana anti Talanhnne Number
<br />I�iiIIIiEIl lli �� �� III II�II�LIi III �� 1�I �Il ill
<br />RXW/,Dwain
<br />GMEMEDICAL PLAZA 1 III
<br />2505 W HAMMER LN 11/11/2021
<br />STOCKTON, CA 95209-2839 (209) 521-6097
<br />CUSTOMER NUMBG131468-750ER GENERATOR'S REGISTRATION M
<br />2A. DESCRIPTION OF WASTE
<br />213• CONTAINER TYPE
<br />2C. NO. OF
<br />CONTAINERS
<br />21). VOLUME
<br />UN3291 Regulated Medical Waste, n,o,s„
<br />6.2, Pod
<br />14RR2-(Pharm) 2 Shelf Wheeled Rack (46 Cuft.)
<br />Cu F
<br />82,PBGIIRegulated Medical Waste, n.os.,
<br />KRR3-(Phan-n)3 Shelf Wheeled Rack (52 Cuff.)
<br />Cu
<br />62, PGIIRegulaledMedlcalWaste,n.o,s.,
<br />RX-(Pliarrn) Gal, COrnlgated Box (4.32 CUR,)
<br />Cu
<br />UN3291 Regulated Medical Waste,n.o.s.,
<br />6.2, PGI/
<br />eox uff,
<br />- arrn a, bl?ti1 acd B 42 C
<br />RX (Ph )_— Gal, C ( )
<br />Cu F
<br />Ll
<br />Z
<br />UN329t Regulated Medical Waste, n.o.s.,
<br />6,2, PGII
<br />CFvrr
<br />`::r
<br />j
<br />1 Cu F
<br />UN32911 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu F
<br />UN3291 Regulated Medical Waste, mo.s.,
<br />6.2, PGI)
<br />Cu F
<br />UN3291 Regulated Medical Waste, n,o.s„
<br />6,2, PGII
<br />Cu F
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />6.2. PGII
<br />Ou F
<br />3, Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 00- Cu F
<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 regons"
<br />,,11
<br />Printed/Typed Name Signature Date W
<br />4. TRANSPORTER 1 ADDRESS: Phone (209) 294-71141
<br />` tericycle., 111C. This Is a Through Shipment Applicable Permit Numbers:
<br />C
<br />7875 R A f3ridgeford Rd. TS/OST-80
<br />y
<br />Stockton, CA 95206
<br />Z
<br />TRANSPORT C RTIFICATION: Receipt of medical waste as described ve.
<br />` _._
<br />Pr1nUlYpe Name r Signature � �1.. Date
<br />6, INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone k:
<br />Applicable Permit Numbers:
<br />=
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />Print/Tvpe Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone p:
<br />Applicable Permit Numbers:
<br />is
<br />c
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />-,
<br />OVA I
<br />:.lcti
<br />Facility: D. Alternate Facility:
<br />SA, Deelgnat c I ea,
<br />hernate Facility: SC, Alternate
<br />i
<br />t ole, Inc. (At ALFA ' tericy
<br />.ie, Inc, (Incinerator) tencycle, Inc, (Autoclave) 1 •ovanta Marion, Inc
<br />I
<br />E 76 A Bridgeford Rd. 0 N. FDxbom
<br />Drive 2776 E. 28th St, 850 Brooldake Road NE
<br />:iokton, CA 9bOM N21 Jortli
<br />alt Lake, UT 84054 ' fernon, CA 40058 1 crooks, OR 97305
<br />11'230)294-7114
<br />801)9
<br />10-1171 888)783-7422 1505)393-0800
<br />10S'i-6�0 g'�a+cs%te A-44
<br />'ea
<br />/JA -36 ernbt# 364
<br />aFeTe,1 W FACILITY: I certify that I have
<br />been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above Indicated was"fes in"176-o
<br />dance with the requirement outlined In that authorization,
<br />Prinl/Type Name
<br />Signature Date
<br />
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