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MEDICAL WASTE TRACKING FORM NUMBER
<br /> as • St@CIC Cl2` IN CASE OF EMERGENCY CONTACT: CFiEMTREC 1400424 9300 STANDARD MANIFEST 001 -03.2t •NocA
<br /> e ROLIIe ;l] . 703 - 418 CUSTOMER No. 21132 MDTKOD0120
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATTR : Erie CCn4^11 ITM
<br /> l TOKAY DIALYSIS V016
<br /> 3 '12 S FAIRM0NTAVE A/5/2022
<br /> LOCM , CA05240 - 3u40 ( 209) 36M418
<br /> 6053303- 001
<br /> CUSTOMER NumuER GENERATOR'S REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 2a. CONTAINERTYPE 2C. NO. OF 2D. VOLUME
<br /> UN3291
<br /> 91 Regulated Medical Waste, mo.s., 1 1 � _ (� lo ) TPq �I_( I~a}11 ) _7ygq_( Inr;ln�rGte ) 1?4 Gal . Tub 16 CS gTA�it�ERs� a
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s., TD21 -fB !o ) 1Fo '15_ (Path ),•„_,_,_TY155 ( CSIerno ),.,,,-. 20Gal . TUb (2 7 C�!lfi . )ur Cu Ft.
<br /> M UN329i Regulated Medical Waste, n.o.s., TCdp- (1✓ iD ) ( -TY4 '1- t } � en� )D T14t3-( lnrinelsfe ) 37 Cal . Tu :) (4 . 9 G1lf'c. )
<br /> 6.2, PGII — -- Cu Ft,
<br /> UN3291 Regulated Medical Waste, n.o.s., 11�t1J'A $- BID GV1{13- C} IEi'no _ __- Wis' 13 Phamii 43 Gal . Tl ! ] 53Cuftcc .
<br /> 6.2, PGII ( ) ( ) ( ) ( ) Cu Ft.
<br /> LLI Z 62, PGi } Regulated Medical Waste, n.o.s., 1 R (Bio ) al . Corr gated Box (<'1 . S�2 Cuft. ) Cu Ft.
<br /> UJI
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s„
<br /> 6.2, PGII Cu FI.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu FL
<br /> UN3291 . Regulated Medical Waste, mo.s.,
<br /> 6.21 PGII Cu Ft.
<br /> 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS / ! 8 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 transport according to alp pa e international and national� governor tat regulatio
<br /> PrintedRyped Name L(�,/it11Signature Date
<br /> CTRANSPORTER 1 ADDRESS: Phone #: ( 209) 2944114
<br /> W `.:alrlricycle , Inc. . � This is R ThroUgh ShilAIWIll Applicable Permit plumbers;
<br /> 0 .7075 R A Britl �ls,ford Rd & l S/Os T- 00
<br /> N Slociclon , CA 95206
<br /> a 4 TRANSPORTER CE ICATIOlN�• : Receipt of medical waste as desc ' 41 °ve, l
<br /> ~ Print/Type Name \ t n Signature ( �S Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> X o Applicable Permit Numbers;
<br /> iUj
<br /> m
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/lype Name Signature Date
<br /> i 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phonetr 12
<br /> #;
<br /> 5 w Applicable Permit Numbers:
<br /> W
<br /> $ ? INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> 41� =
<br /> z Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 1 SA. eignated FaclAilU: �l Eq ER ea. A emate Facliky: 8C, Alternate Facility: 8D, Alternate Facility:
<br /> Q 3 ;role , Inc . (Autc4clave) Steriv ]le , ino. (Indnerator) Ste9kyLle , Inc. . (AUtoolemle) Covanta Marin , Inc.
<br /> v � 787 FSA Grid 9Q 11a 'oxboro Drive 2775 E . 25th St, 4850 Brooklake Woad NE
<br /> W f Sto than , CA 9. 2022 Norte "alt Lake , UT 84054 Vernon , CA 91858 Bwoks, OR 97335
<br /> w og1 (28< 1294 - 711 # (801 ) 38- 1171 (866)78S41122 (505)3'93- 0890
<br /> $ s 1-9t: . T= 800" 3A-el ' OMA-So Fern*4 :3b4
<br /> ki TREATMENT een authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the above Indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type Name Signature Data
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<br /> I ORIGINAL
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