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0-6.10
<br />i� StericyCle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.424-9300 STANDARD MANIFEST001.03.2t•NOCA
<br />RAute #2 123 — 16 CUSTOMER NO. 21132 MDFROOP4PK
<br />1 r;PnPratnr'R NPmn- Address and•Teleohone Number
<br />TransNntad comakwR, cu t to : Brooks, OR
<br />Transh ill cors "n, cu t b : N. Sak Lake, UT
<br />- - ATTN:Mvidis �I I�IaIiN�� I{ i I II Ill�lllN��I�N�,III
<br />SGMP STOCKTON MEDICAL PLAZA 1
<br />2505 W W*NMER LN
<br />STOCKTON, CA 95209- 2839
<br />GENERATOR'S REGISTRATION #
<br />CUSTOMER NUMBER 04
<br />2A. DESCRIPTION OF WASTE
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<br />10 CONTAINERTYPE
<br />2C. NO, OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
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<br />CONTAINERS
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<br />UN3291 Regulated Medical Waste, n.o.s.,
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ►(lip
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />itlon for transport to International a regulallons"
<br />are In all res n proper co according applicable and natloni?' rimutal
<br />P4nt:TypZN,� Signature
<br />4.TRANS RTER DRESS:
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<br />Phone N:�-7422
<br />Applicable Per
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<br />41 W.
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<br />TRANSPORTER CERppCA&IbIV: descr d
<br />Receipt or medical waste as ab
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<br />PrinVfype Name Signature
<br />5, INTERMEDIATE HANDLER 2 /TRANSPORT9-8 2 ADDRESS: _
<br />Dale `
<br />Phone N:
<br />Applicable Permit Numbers;
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinUType Name Signature
<br />Date
<br />8, INTERMEDIATE HANDLER 3 /TRANSPORTER a ADDRESS:
<br />Phone N:
<br />a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Applicable Permit Numbers:
<br />Prin Name Signature
<br />Dale
<br />7, DI REPANCY INDICATION
<br />78A.
<br />Designated Feclltty; 88, Alternate Facility: 8C. ANernals Facility:,
<br />❑ 8D. Altemale Facility:
<br />le, llnc, (mociiirve) Stericyde, Inc. (Incinerator) 9boricycle, Inc. (Autodsve)
<br />Covards Marion, Inc
<br />4196 W. 9wIItAV*90 N. FaXbot'o atNe 1661 Sh4 bon drNe
<br />4850 Brocidala Road NE
<br />Fresno, CA 93722 North SaR Lake, UT 94054 Hollldar, CA 95023
<br />Brooks, OR 97305
<br />(8fi6�ORTIZ (801)936-1171 (966)783-7422
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<br />(d05)3A3-n99n
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<br />3A-4481JA-36 TSMT-8"3
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<br />TREATMENAkCIAMItlfy that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above Indicated wastes In accordance with the requirement outlined In that authorization,
<br />Print/Type Name Signature
<br />Dale
<br />TransNntad comakwR, cu t to : Brooks, OR
<br />Transh ill cors "n, cu t b : N. Sak Lake, UT
<br />
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