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MEDICAL WASTE TRACKINU PUHM NUMbt: K
<br /> �i e� Stericyc � e� IN CASVF F,M r ENc,Y, QNTACT: CHEMTREC 1 600 d24 93Do STANDARD 1 1 T �i-03.21 •NOCA
<br /> t{ UI 3F ! Uq 1 E CUSTOMER N0. 21132 tj� 11J
<br /> 1 . Generat W."Tree CrowleydTelephone Number11 � I II1TOKAAAYDIALYSIS-DAVITA X120 `16 I 1
<br /> 312 S FAIRMONTAVE 3/4/2022
<br /> LODI , CA95240-3840 (209) 369- 5418
<br /> 6053303- 001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTt 28 . CONTAINER TYPE 2C, NO. OF 2D. VOLUME
<br /> 623291 Regulated Medical Waste, n.o.s., TB14- (BID ),. aTP14- ( Path ) TY14-( Incinerate ) 44 Gal . TUb ��
<br /> 7 74CU Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o,s., TB21 - (Bio ) TP1 v-(Path),.,,��TY15-( Chemo ) 20 Gal . Tub ( .7 Cuft . )
<br /> 6,21 PGII Cu Ft.
<br /> OUN3291 , Regulated Medical Waste, n.o.s., T]349-(Bio ) TY49-(Chemo ) T149-( Incinerate) 37 Gal . Tu (4 , g Cuft. )
<br /> 6.2, PGII Cu Ft.
<br /> Ft U3291Regulated Medical Waste, n,o,s., WE143-{ Bio ) CVA3-(Chemo )_ W�(43-( Pharrrt ) 43 Gal . Tu (5 . 7Cuft .
<br /> Ft N
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<br /> Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s., KR (Bao ) Gal . Corrugated Box (4 . 32 Cut )
<br /> u 6,2 , 13611 Cu Ft.
<br /> UN3291
<br /> � Regulated Medical Waste, n.o.s., Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,0.s.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,os.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, mo,s.,
<br /> 6,2, PGII Cu F
<br /> 3. Generator's Certification: °I hereby declare that the contents of this consignment are fully and accurately TOTALS 110� �, .t� � Cu Ft.
<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 tran ort according to applicable international and national governm 1 regulations:'
<br /> Printed/Typed Name Signature Date
<br /> 4. TRAN R $S; hone #:
<br /> cr F�'�6��t`�9n� . This is a Throu h � ' entrI�
<br /> 0 7575 R A Bridgeford Rd . Applicable Per l My 80
<br /> 06 Stockton , CA 95206
<br /> CL < TRANSPORTER RTIFICATIO Receipt of medical waste as describ^eove.
<br /> ~CC
<br /> Pdnt/Type Name Var{ Signature �?:+ " «— --- Date 03 W
<br /> S. INTERMEDIATE HANDLER 21TRANSPORTER 2 ADDRESS: Phone #:
<br /> CC Applicable Permit Numbers:
<br /> l INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> C INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> Jig g Applicable Permit Numbers:
<br /> aJ
<br /> S M T INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Z
<br /> — PrinUType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> LR SA. pesigna I 88. ANernate Facility: eC. ANarnats Facility: I] 8D. Alternate Facility:
<br /> eric � 0S , ,I'j, , n (incinerator)ei , IStericyale , Ina . (Autoclave) Covanta Mahon , Inc
<br /> v 7875 RA Bnd9efolr 9 N , Foxboro grave 2775 E . 28th St, 4850 Brooklake Road NE
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<br /> UM Stockton orth Salt Lake UT 84054 Vernon CA 80058 Brooks OR 9
<br /> � � � 20�z i , 7305
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<br /> (209 )294-7114 ( 01 )936 - 1171 (888)783-7422 ( 50'5 )383-0890
<br /> TSIOST= 80 A"448/JX
<br /> 36 Pemit # 364
<br /> 7a- �
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<br /> ATMENT FACILITY: rtify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> Imo- receive tes 11 with the requirement outlined in that authorization .
<br /> Print/Type Name Signature Date
<br /> I(
<br /> I
<br /> ORIGINAL
<br />
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