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*.-.o S�e1�'�CVC�ee IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-424.9300 STANDARD MANIFEST 001.03.21•NOCA <br />J R01.11e ;ft 7105 -1 1 CUSTOMER NO, 21132 MOT00053R <br />1. Generator's Name. Address and Telephone Number <br />ATTIV: DvJal11 Dauglu„811 <br />RXW/• GMF MEDICAL PLAZA `( <br />2505 W HAMMER LN <br />11/13/2021 <br />STOCKTON, CA 95200-2839 r (209) 529-6097 <br />6131463-7501 <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION M <br />2A. DESCRIPTION OF WASTE <br />219. CONTAINER TYPE <br />2C. NO, OF <br />CONTAINERS <br />20. VOLUME <br />UN3291 Regulated Medlcal Waste, n.o•s., <br />KRR2-(Pharm) 2 Shelf Wheeled Rack (48 CUR.) <br />6.2, PGII <br />Cu <br />823 PGII Regulated Medical Waste,n.os., <br />KRR3-(Phami) 3 She]Mfteeled Rack (62 CUR,) <br />Cu <br />a <br />0 <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2. P(311 <br />07 <br />RX-(Pharrn)__Gal. COITLlfjated Sox (4.82 Cuft.) <br />Cu <br />U2, PGI Regulated Medical Waste, n•o.s•, <br />6.2, PGII <br />- Pharrn Cal, COt111 ated Box 4.32 Cuft, <br />RX ( ) 0 ( ) <br />Cu <br />WUN3291 <br />Regulated Medlcal Waste, <br />6,2, PGII <br />rC Q O <br />Cu <br />tZ <br />a <br />UN3291 Regulated Medical Waste, n.o.s., <br />914 nn p <br />6.2, PGII <br />`p(( p0 O. <br />Cu <br />UUN3229G11I Regulated Medical Waste, n.o.s., <br />�CC V 11 .lov <br />o <br />�. 3 Cu <br />UN3291 Regulated Medlcal Waste, n.o.s., <br />6.2, PGII <br />Cu <br />UN3291 Regulated Medlcal Waste, n•o.s„ <br />6.2, PGII <br />C <br />3, Generator's Certification: "I hereby declare that the contents of this conslgnnient are fully and accurately TOTALS <br />2 , 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 regulations" <br />1 d <br />Printed/T ed Name Signature <br />Date <br />4. TRANSPORTER 1 ADDRESS: <br />Phone k; (209) 2911-7'194 <br />SlariGyCle, h1C. This is :I Through Shipment <br />7875 R A Bridgeford Rd. � <br />Applicable Permit Numbers: <br />TS/OST-80 <br />50 <br />E N <br />Stockton, CA 95206 <br />Z <br />TRANSPORTER CERTIFICEv <br />N: Recelpt of medical waste as des=1-.,L <br />'lit <br />y <br />n <br />PrInVType Name Signature <br />Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone /f; <br />i <br />Applicable Permit Numbers: <br />t s <br />l <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinIf ype Name Signature <br />Date <br />i <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone g: <br />Numbers: <br />Applicable Permit <br />E <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Ila <br />Print/Type Name Signature <br />Date <br />7. DISCREPANQY INDICATION <br />signated Facility: 88. <br />Alternate Facility: ❑ 8C. Alternate Facility: <br />Alternate Facility: <br />7 <br />ri ycle, Inc. (Incinerator) Stericycle, Inc. (Autoolave) <br />Coventa Mation, Inc <br />Icyc <br />RA 90 <br />A <br />N Foxboro Drive 2775 E. 26th St, <br />4650 BrooNake Road NE <br />tockton, C/� Pic <br />ktk Salt Lake, 11T 84054 Vernon, CA Q-0068 <br />Droek% QR 97305 <br />� <br />)294-7114 (8( p (8 <br />1;336-1171 (866)783-7422 <br />(505)303-0880 <br />E <br />S/UST BI� m �U��2i 3A <br />8/JA-3t3 <br />Permit# 3x34 <br />CP <br />T EATMENT F CILIT certify that I ha <br />ie been authorized by the applicable state agency to accept untreated <br />medical wastes and that I have ' <br />- <br />r Blued t tes Ina <br />oi dance with the requirement outlined In that authorization. <br />Signalure <br />Date <br />