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MEDICAL WASTE TRACKING FORM NUMBER ' <br /> Stericycle! iN CASE OF EMERGENCY CONTACT; CHEMTREC 1 .10042,-10W STANDARD MANIFEST 001 -0341 •1400A <br /> Route 709 . 11 CUSTOMER NO. 21132 MDTKOO 't CZM <br /> 1 . Generator's Name, Address and Telephone Number <br /> ATTN : Erle Crowley <br /> III 11111111III <br /> TQKAY E?1RLYSIS-IAMDAVlTA #2016 <br /> 312 S FAIRMONTAVE 2/10/202' <br /> LODI , CA95240- 3840 ( 209) 369- 5418 <br /> 8053303- 001 <br /> CUSTOMER NuMs&R GENERATOR'S REGISTRATION N <br /> 2A. DESCRIPTION OF WASTE 29. CONTAINER TYPE 2C. No. OF 20. VOLUME <br /> 1.1113291 Regulated Medical Waste, n.o.s., TH43( 81o ) TP43( pa ) TC43( Ch ) TX43( Ph ) Gel ( d <br /> 6.2, PGII I Cu Ft. <br /> UN329PGI1Regulated Medical Waste. n ,0.s„ TH31 ( Bio ).__-_ TP31 (Pa ) 7C31 (Ch ) TX31 (Ph ),_ 31GalTu (4 . 1Z Qu Ft. <br /> O UN329IRegulated Medical Waste, n.o.s., KP (Blo ) RX ( Pharrn ) Corrugated Bax ( 4 . 3 ) 1 <br /> Cu Ft. <br /> 623 291) Regulated Medical Waste, n.o.s., p X GAL/QT Gasketed Sharp Cont , ( CuFt ) <br /> CC moo Cu Ft. <br /> W UN3291 Regulated Medical waste, n,o.s„ SH GAL/QTGasketedShar Cant . CuFt <br /> `Z 6,2, PGII p ( ) Cu Ft. <br /> UN3291 Regulated Medical Waste, n,o.s„ <br /> 6.21 PGII Cu Ft, <br /> UN3291 Regulated Medical Waste, n.o.s„ <br /> 621 PGII Cu Ft. <br /> UN3291 Regulated Medical Waste, n.D.s„ <br /> 8,2, 1'131{ Cu Ft. <br /> UN3291 Regulated Medical Waste, n.o.s„ <br /> 6,2, PGIi Cu Ft. <br /> 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS b I ISO <br /> Cu Ft. <br /> described above by the proper shipping name, and are classified, packaged, marked and labell"placarded, and <br /> are in all respects in proper condition for transport according to applicable international and national governmental <br /> Ix <br /> P Name tha) r Avo Siewmifttura oase mhg <br /> i. TRANSER 1 ADDRESS: Phone M; ( 209) 294JI14 <br /> CtTCyCle , Inc . This 1s a Through shipment Applicable Permit Numbero0 <br /> 7875 R A Bridgeford Rd . TS/015� T 80 <br /> S Stockton , CA 95208 <br /> M f� ANSPORTS <br /> aTRFICATI 4AX of medical waste eceip t as described a t <br /> ve. �} l <br /> ~ Print) Type Name l� Signature j . <br /> Lid 1 Date (3402 <br /> 6. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: phone N; . <br /> N Applicable Permit Numbers; <br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above. <br /> PdnVType Name Signature Date <br /> ti. INTERMEDIATE HANDLER 3 ! TRANSPORTER 3 ADDRESS: Phone M; <br /> Applicable Permit Numbers: <br /> x INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> s Prfnt(rype Name Signature Date <br /> 7. DISCREPANCY INDICATION <br /> DesignOW FsCIIMys 88, Albmate Faclllty: aC, Alternate Faollfty: 9b, ARamab FacilRy; <br /> MOONS� aterloycle , in A*ool3v ) Stericyole , Inc . (Autos- lave) Sterloycle , Inc . (Autoclave) Covanta Marion , Inc <br /> 7875 RA 8 •1551 Shefton Drive 2775 E . 213th St , 4860 Drooklake Road 111E <br /> CA <br /> Stockton , Hollister, CA 95023 Vernon , CA 00058 Brooks, OR .97305 <br /> W (209 ) 204TEO 1 32023 (866 )783-7422 (886 ) 783-7422 j505 )393-05!30 <br /> T�lUuT 80 T91CroT41 2 Permit # 364 <br /> P12 <br /> TREATMENT �ITY:T"certity that i have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> H received the above Indicated wastes in accordance with the requirement outlined in that authorization , i <br /> PNnVType Name Signature Date <br /> i <br /> ORIGINAL <br />