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MEDICAL WASTE TRACKING FORM NUMBER
<br /> -9 Stericycle° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1400424-9300 STANDARD MANIFEST001 .03.21-NOCA
<br /> ROLIte lf 706 - 16 CUSTOMER NO, 21132 IVID K. 00t i6s
<br /> I . Generator's Name , Address and Telephone Number iE
<br /> A -iN : Frgfa% t�i4;pfl y al ia � ldEllIII QI Ii I i � i� lII �� �TOKAY GIALYSI ;_ D!-0%Vl �F/t 4128 •iG 1 � � 4 �. 171
<br /> 3 � 13l " li I
<br /> 311 '0.-'. `s FAIRIllCINTANIE =1 / I5/2022
<br /> LODI ) CA9521 'M � 3040 ( 200) 36M418
<br /> CUSTOMER NUMeen GENERATOR'S REGISTnxn0N #
<br /> 2A, DESCRIPTION OF WASTE 20• CONTAINER TYPE 2C, NO, OF 2D, VOLUME
<br /> UN329i Regulated Medical Waste, n,o.s„ _ , ii , , t CONTAIN
<br /> 6,21 PGII F �14 (Ela10 ) 1 _._ TP1 �1 - ( F"':3tn )_ _ T1 1c, ( Inoine-rate )_� ell] Gal . Tub 5 . ?cuFt14 cu Ft.
<br /> 623PGIIRegulatedMedical Waste, n.o.s„ TIS. 1 - (Cial _ TP1 "� (P �th ) �- Y15W( Clwlerrl0 ) _ 20 i � al . TUU ( ,7 Cuft , 1
<br /> Cu Ft,
<br /> UN3291 Regulated Medical Waste n.o,s.,
<br /> O 6.2, PGII r I P *l (8io) .._..._T '• 4Pm(t=,hCi'iir, )_._._TW0I ( Inoinerate ) " 7 tial , Tu a (4 . 0 Guff. ) Cu FL
<br /> 623PGIIRegulated Medical Waste, n.o,s,, � rti; 121 -( Sio )_ _ w-C\A%(J3_(Chetno )— ti.Al.{42c ( Pharrrl ) 43 Gal . 110 ( 6 . 7CLIft , )
<br /> Cu Ft,
<br /> W UN3291 Regulated Medical Waste, n .o.s ., , . , C,
<br /> W 6.2, PGII i � , . .� _( iCs ) _„__,_Gal , !=*Orru0 :M ted vo ;< ( 4 . J2 C�tlfi. ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s„
<br /> 6,2, PGII Cu Ft,
<br /> UN3291 Regulated Medical Waste, n,o,s„
<br /> 6,2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,$ ,,
<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 1110o 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 properT41
<br /> Ion for transport according) to applicable international and national governmental regulations.'
<br /> Printecirryped Name � J �' Signature • � �r Date
<br /> 4a TRANSPORTER 1 ADDRESS: _ Phone #: ( 209 ) 2941"11 -t
<br /> `� ti; l 'tG Glit , Inc . This kc; a Throur.ill Applicable Permit Numbers:
<br /> 787 3 R A BriiicWord RIAL I r, rt�L, i 011
<br /> a N `; Iejcttton , trA 952110
<br /> 9L a TRANSPORTER CERTIFIQATJON : Receipt of medical waste as describe ove,
<br /> ►�- (j1 ?
<br /> Print/Type Name owal
<br /> _ Signature ?Ark
<br /> 8. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> Applicable Permit Numbers:
<br /> Uj
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> PrinMpe Name Signature Date
<br /> ro 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> In Applicable Permit Numbers%
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> z
<br /> PNSignature Date
<br /> rinype ame
<br /> T. SCREPANCY INDi USE
<br /> RlJ7*OC AVtFq
<br /> y 8A. Designater� ��p�i►�v�j 8 . Alternate Facility, SC, Ahernats Facility: BD, Altemata Facllky:
<br /> J Ierit;rcfe , Inc . t'r,ula r. f �z stc icycle , Ince , (Incinerator) titerioyole , Ino . (Autoclave) Covanta Marlon , inc
<br /> V
<br /> @75 ,R A Dridgeiord Rd . 90 j4 . Foxboro Drive 2176 E . 213th St , 4X60 DrooWnkv_ Road NE:
<br /> � toolttc! A Ari irl' 1 N , rTh Salt Lake , UT 24054 Vernnn , CA 90058
<br /> Brook . , 01"? 97 "3135
<br /> E13 i� ,: � ' . . �t " � 1 �. , (?' il ) 2336 - "1171 (86151 )70 "_ 7422 (505 ) 393 . 0890
<br /> g o aft TSfOS = 30 t t 44tij� � � �� Pp. rmii d
<br /> a
<br /> W 0 TREATMENT FACILITY: I certify that I have been authorized by the applicable stale agency to accept untreated medical wastes and that 1 have
<br /> I— received the above Indicated wastes in accordance with the requirement outlined in that authorization ,
<br /> in Prin*pa Name Signature Date
<br /> ORIGINAL
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