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MEDICAL WASTE TRACKING FORM NUMBER <br /> g®® Stericycie• IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800-424.9300 STANDARD MANIFEST 001.1a0"TD <br /> • PietetlinpPeople.RodgapRIA, Route 0: 123 - 21 CUSTOMER NO.21132 MDFR00UQ8I <br /> FI.Ge6erator's Name,Address and Telephone Number � �� �� � ■�I� � ( � �� ��� F� ���� <br /> ATTNaTerri Grenz 1 I <br /> SATELITTE DIALYSIS — STOC TON <br /> 590 E EARDxNG WAY <br /> STOCK'TON, CA 95204— 6110 <br /> (209) 774-5800 10/3/2017 <br /> CUSTOMER NUMBER (5077750-042 GENERATGR'sREGIsTAAnoN# <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINERTYPE 20. NO.OF 2D. VOLUME <br /> UN3291 Regulated Medical Waste,n <br /> 6,2,PGII TBOS — 40 tial Tub (Bio) (5.3 Cu ft) Cu Ft. <br /> UN3291 Regulated Medical Waste,n,o.s., TB4 g — 37 Gal Tub {Bio) {4.9 Cu ft)6,2,PGII Ou Ft. <br /> 0 6 23PGII Regulated Medical Waste,n.o,s., <br /> OBl - 44 Gal Tub(Bio) (5.9 Cu tt) t <br /> UN3291 Regulated Medical Waste,n.o.s., T921—(BTO)/TP15—(Path)/TX15—(Chemo)20 Gal Tub(2.7CUFT) <br /> cc 6.2.FGII <br /> Cu Ft. <br /> W UN3291,Regulated Medical Waste,n.o,s., WB31—(Bio)/ti P31—(path)/ C31—(Chemo)31 Gal Tub(4,14CUFT <br /> 6 2,PGII Cu Ft. <br /> 6.2.PGII ReAulatad Medical Waste,n.o.s., WB43—(Bio)/FW43—(Fath)/CW43—(Chemo) Gal Tub(5.7CaFFT) <br /> Cu Ft. <br /> 623 PGII Regulated Medical Waste,n.o.s., MB — Biosystems Cardboard Bose (4.2 cu ft) <br /> Cu FL <br /> UN3291 Regulated Medical Waste,n,o.s., <br /> 6.2,P611 Cu Ft. <br /> UN3291 Regulated Medical Waste,n.o.s., <br /> 6.2,poll' u Ft <br /> 3.Gen is Certification:•I hereby declare that the contents of this consignment are full/and accurately TOTALS ® ;,Ft. <br /> des a ve by the proper shipping name,and are classified,packaged,marked and labelled/p air ed, nd <br /> a rf&'!t resp cis In proper d it n for t rltport cc to p I mational and national n me r ul t s" <br /> I (//�` <br /> ;Printed ped Name SI Lure -` e <br /> 117 <br /> 4.TRANSP ER 1 ADDRESS: , Phone 11: (13 66)783-7422 <br /> us Stericycle, Incl. This is a Through Shipment Applicable Permit Numbers: <br /> a 4135 W. Swift Ave Hauler Reg# 3400 <br /> Freano,CA 93722 <br /> m a TRANSPORTER CERTIFICATION: elpt of medical waste as described ove <br /> Prtnt/Type Namea4 Signature Date G <br /> S.INTERMEDIATE HARMER 2 RA SPORTER 2 ADDRESS: Phone#: <br /> a s Applicable Permit Numbers: <br /> 8;1&W Pu <br /> i INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> 6,INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS. Phone#- <br /> g Applicable Permit Numbers <br /> N INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Printllype Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> 8A.Dosignated Facility; 8B.Alternate Facility: ❑8C.Alternate Facility: 81).Alternate Facility: <br /> "-abrlcyule,Inc. Shirlaycle,Inc. 3terlcycle,inc. <br /> <br /> <br /> <br /> <br /> oC TREATMENT FACtL ff-l` Ify that I have been authorized by the applicable state agency to accept untreated medical wastes and chat I have <br /> t— received the above indicates wastes In accordance with the requirement outlined In that authorization. <br /> Print/type Name Signature Date <br /> Triandeffed conte ners, ou a to <br /> ORIGINAL <br />