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MEDICAL WASTE TRACKING FORM NUMBER
<br /> • * . Stericycle° IN CASE OF EMERGENCY CONTACT: CHEMTREC 14800-424.9300 STANDARD MANIFEST 001 .03.21 •NOCA
<br /> Route * 703 . 15 CUSTOMER NO, 21132 MDTKOCIOFXM
<br /> i . Generator's Name, Address and Telephone Number
<br /> ATA Eric CrowleyCrowley
<br /> TC� KAY DIDIALYSIS-C)AVlTA #2016
<br /> 312 S FAIRMONT AVE 3/15/2022
<br /> LODI , CA 95240-3840 ( 209) 3x60- 5418
<br /> f 6053303- 001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO, OF 213, VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., T014-(Bio ).LTP14 - ( Path ) TY14- ( Incinerate ) 44 Gal . Tub effivjE S �j
<br /> 6.2, PGII ' 7 1 • Cu Ft.
<br /> UN3291 Regulated Medical Waste, T B21 -(Bio ), TPIS-(Fath )„ Y15-( Cl7erno ) 20 Gal . Tub ( 2 .7 Cuff . )
<br /> Cu Ft.
<br /> 0 UN3291 Regulated Medical Wastt;, n,o.s., T !340- (BIO ) TY4P!- (Chemo ) T14 �1-( 1n f rate ) 37 Gal . Tu (4 , 0Cult. ) Cu Ft
<br /> a UUN329G11iRegulated Medical Waste, n.o.s., VvB43-( Bio )_.CVASw(Cherno ). VVX43-( PhaITA ) 43 Gal . Tu ( 5 , 7Cuft . ) Cu FL
<br /> Q
<br /> UJ UN3291 , Regulated Medical Waste, n.o.s., KRB ( )BIO Gal . Coma ated Box (4 . 32 Cult. )
<br /> 2 6.2, PGII Cu Ftp
<br /> UJI
<br /> UN3291 Regulated Medical Waste, n,o.s.,
<br /> 6.21 PGII Q d ` U e Cu Ft,
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.2, PGII Cu Ft,
<br /> UN3291 Regulated Medical Waste, n.o,s., Cu Ft.
<br /> 6.2, PGII
<br /> UN32911 Regulated Medical Waste, n.o.s., 4Cu Ft.
<br /> 6.2, PGII
<br /> 3. Generator's Certification : "I hereby declare that the contents of this consignment are fully and accurately TOTALS 5 Cu FI.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, d
<br /> are in all respects In proper condition for transport according to applicable International and national governm let ulation
<br /> Printed/Typed Name Signature to W1 &Ae:,
<br /> W 4. TRANUS encycRTER1Ae , tic S: n Simple
<br /> q:
<br /> [[ 11 r This tS %q Through ,�Il pie Applicable Permit Numbers:
<br /> 7075 R A Bridgeford Rd . TS OST 80
<br /> Stockton , CA 05206
<br /> a a TRANSPORTER �F�ryp•�� IFIL I N ' Receipt of medical waste as describ ve,
<br /> ~ PrInUTypo Name , ��Q� � n1 Signature L4 &��� Oate .
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Print/Type Name Signature Date
<br /> M 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS : Phone #:
<br /> a Applicable Permit Numbers:
<br /> 8 x INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> — PrinVrype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> "209 )294m7114
<br /> y: 8% Alternate Facility: 8C. Alternate Facility: 8D. Alternate Faclllty:
<br /> S � a eri ycle , Inc . (Incinerator) Sterloycle , Inc , (Autoclave) Cavanta Marion , inc
<br /> CUM) 80 k7 Foxboro drive 2775 E . 28th St, 4850 Brooklake Road IVB
<br /> is LEA Noril I Salt lake , UT 84064 Vernon , CA 90068 Brooks, OR 07306
<br /> I=d 9 $ (801 936 - 9171 (806 )783-7424 (ra05 )393-0890
<br /> _ Src.�ST 80 MAR X 7 2022 ,-�I BIJA- a pe t ; e h�, ;on inc.
<br /> %
<br /> 4�oa � % , .' •m, OR 97305
<br /> Q � 6 tlw: u �tc,i
<br /> X T EATMENT FACILITY: i certi that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> H r ceived th� ,e I V; s In acco dance with the requirement outlined In that authorization , MAR 2022
<br /> P int/Type Signature Dale
<br /> (603) 3�3 03S0
<br /> t100. 11(S3434
<br /> ORIGINAL
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