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MEDICAL WASTE TRACKING FORM NUMBER
<br /> J'teir' � CVG' � �i® IN CASE OF EMERGENCY CONTACT: CHEMTREC1wSM424-9300 STANDARD MANIFEST001 •o3.21 •NOCA
<br /> J/ R011.1113 #. 706 - 5 CUSTOMER No, 21132 MDTKp ()() GBZ
<br /> I . Generator's Narhe, Address and Telephone Number
<br /> ATTN : Erie Crowley
<br /> � �
<br /> TOK'AY DIAIvYsI S- DAVITA #1016
<br /> 312 S FAIRMONTAVE 3/18/2022
<br /> LODI , CA95240-3840 ( 209) 369- 5418
<br /> 6053303- 001
<br /> CUSTOMER NUMBER GENERATOR's REGISTRATION N
<br /> 2A . DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C, No. OF 20. VOLUME
<br /> UN3291 , Regulated Medical Waste, n.o.s., TB14 - (Bla ) 1 TN4_( Path ) TY � 4- ( Incinera#e ) 4Q Ca1 . Tub u E C
<br /> 6.2, PGII 53. Cu Ft,
<br /> 623PGIIRegulatedMedicalWaste, n.o,s., TB21 -(Bia )� TP15A (Path )___-„TY15-(Chemo )_,_,•__„ 2a Gal . Tub (L . 7 Cuft . )
<br /> Cu Ft.
<br /> CC 62GIIRegulated Medical Waste, n.o.s.,
<br /> , PTB493 ( Bio ) T1(49- (Chemo ) TI40-( lnrinerate )____,__ u7 Gal . TLi (4 , E' Cuft. ) Cu Ft.
<br /> 623PGIIRegulatedMedicalWasfe, n.o.s., Z1�4 $_( elo ) CVl4.f3- (Chemo ) WX43`( Pharrri ) 43 Gal . Tu (5 . 7Cuft, )
<br /> W UN3291 Regulated Medical Waste, n.o.s,, 7 cc
<br /> Cu Fte
<br /> tZ s.21PGii KR (Bio) Gal . Corrugated Box ( 4 .32 Cult. )
<br /> Cu Ft.
<br /> 0 UN3291 Regulated Medical Waste, n.o,s„
<br /> 6.2, PGII Cu Fl.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu FL
<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGI) 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 0 Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br /> are In ail respects in proper condition for transport according to applicable International and national government egulatlons:' �/
<br /> Printed/Typed Name � � s� �'r`'r V ` Signature Date r{ I Z�
<br /> 4. TRANSPORTER i ADDRESS: Phone M. ( 20 ) ,' ] 1 ( c
<br /> W � t�ncyCle : Inev Tills Is a Through Ship 3lent Applicable Permit Numbers:
<br /> 0 7875 R A 60dyeford Rd . TS/OST 00
<br /> CL Stockton , CA 95206
<br /> a Z TRANSPORTER C TIFICA(TTI1,Oy N: Receipt of medical waste as described ove, (y Jl
<br /> PrinVType Name q�_ s+ �� Signature "�` Date 03It L5 aj06.L .
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> a Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> IY Printfrype Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> ' $ INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> z
<br /> a
<br /> — PrinUrype Name Signature Date
<br /> 7, DISCREPANCY INDICATION
<br /> 8A. DeeignAt>ldrF ; n 88. Alternate Facilltyr [j 80. Alternate Facllltyr El 8D. Alternate Facility:
<br /> teary c . Au Drcllava tericyole , Inc . (Incinerator) Stericycle , Inc . (Autoclave) Covanta Marion , Inc
<br /> II 4850 Brooklake Road i�1E
<br /> LE a 7375 0 N . Foxboro Drive 2775 E . 26N� St,
<br /> Stocict s � q dDrth Salt Lake , UT 84064 Vernon , GA 80058 Brooks, OR 97305
<br /> Z
<br /> (209 }2 1 ff
<br /> 8q1 }9381171 (866)753,7422 (505 ) 3934890
<br /> � TW/riaT80 ' "- � .3A-9�1t3/iA-3b Permit # 364
<br /> TREOpfEW Fi��ltWVAC0Prtify that have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> mLv,1veq the a above indicated wastes f accordance with the requirement outlined in that authorization ,
<br /> printlTypa Name Signature Date
<br /> P .
<br /> AD
<br /> ORIGINAL
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