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MEDICAL WASTE TRACKING FORM NUMBER
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<br /> ricycle• IN CASE OF EMERGENCY CONTACT: CHEMTREC slasIM424-9300 STANDARD MANIFEST 001 .03.21 •N00A
<br /> Route 1.: 7013 - 1 .1 CUSTOMER N0, 21132 i1f1M000PUT
<br /> I . Generator's Name, Address and Telephone Number ggtall,
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<br /> ATTN : Eric Crsay.rlo�r111 ,11111111111171111C I l a ll,� # iI III
<br /> -i`C� I-`,AY EllAr(SIS,sDAVITA x 20 .1r i Jill
<br /> 11 3 €S � i it 115 1111 Al 1 :131 'i2 'r1MM ill 1 Mil
<br /> 312 S FFAII2tUiofxr AVE 6/2112022
<br /> LOU ; CA95240- 3210 ( 209) 300- 5418
<br /> CusTOMEH NUMBER C 05^ ~ y - 001 GENERATaR's RKi1sTpATm a
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C. NO, OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n,o.s,, 1 C-, x, •t��, • CONTAIN
<br /> ELS
<br /> 62, PGII T '1 } 0113 )_ _ 1 P '14 ( i clan )- - l i 14 -( Inain�l ate ) dry gyral . T Ib b �+ �'
<br /> . C:ft IV
<br /> Cu FL
<br /> 62. P Ii Regulated Madical Waste, moss*' T B2411 ( ' io ) TP 16,w (Psath )-r..__TVl �-( C- he. rrla )•,_•_- �L� rr � l . Tub (� .7 Cults ) Cu Ft.
<br /> CC UN3291 , Regulated Medical Waste, n,o.s., T B4Q Bin ,.1 P _ C� heni0 -_•_ T1. 0,,, ndnei esta . T u D '^ . 7 Ctlft .
<br /> 6.2, PGII ) TY
<br /> --_ ( ) I
<br /> ( ) 37 Gal . ( ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s., ,,7 B r, 1310 �� Cid r y r } it rtt 3 1fllX� ?- f�i�3 t'r i ) 4 �3 Oa al . Tu ] '5 . 7CUi1: ,
<br /> CC 6.21 PGII ( ) ( )-• — ( ( ) Cu Ft.
<br /> W 623PGIl 291 Regulated Medical Waste, n.o.s„ IrR _(00 ) �T 4; 71 . C oisru }Jatad' Bo'„ (4d . 32 C'uIt's 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 /> 62, PGII Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 621 PGII Cu Ft.
<br /> UN3291 , Regulated Medical Waste, ri.o,s.,
<br /> 6.2, PGii CM
<br /> Ft.
<br /> 3. Generator's Certification: "1 hereby declare that the contents of this consignment are fully and accurately TOTALS ► . Cu Ftt
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelledlplaoarded, and
<br /> are In all respects In proper condition for transport according to applicable Intern it 1 and national governmental regulations." ��,,,�� '����Q
<br /> Print Name nature �got f�'^ .- Dais ��
<br /> 4. TRANSPORTER 1 ADDRESS: _ Phons #: ( 209) 204. 7114
<br /> %i ilii jtuVI111L411111p a emt Applicable Permit Numbers:
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<br /> 0
<br /> 7875 R A Bridgeford Rd .
<br /> r` 1,ICrCnil? i7 , CA 95206
<br /> � � •.
<br /> IRE Q TRANSPORTER CERTIFICATION : Receipt of medical waste as describbeedA .
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<br /> Printlrype Name_ Cal Signature Gc�n -�-- -- Date � 107 ZZ
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; Phone B:
<br /> a Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinUrype Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS. Phone #;
<br /> 4s Applicable Permit Numbers:
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<br /> (Am a i INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br />: a � x
<br /> Print/type Name Signature Date
<br /> T. DISCREPANCY INDICATION
<br /> y SA. Designated Facility: 88. Attarnats Facillty: F1 act Anamab Facility: Oio. Altemab Facility*
<br /> J a eric'fcic , Ino , (AUtorldw ) at'3ri =yclP , Inc. . (In %in: rcltor ut' rlGl 11 _ Inc. . (r� Ut4 I3V?} or .: r'lta�: ' o
<br /> } 1 ' f:i � rlan , Inc.
<br /> 72, 76 R A Bridgeford PH, 00 N Foxboro Drive 2 775 i; . Is' nth 5I , 4650 F 1.3o !<lake Road NE
<br /> LLtG3ktcan , f,r/ . L15610 i'lortn ;', pit : ? t.Jat} / e nor: , 1 :Ft ! ,8 Brooks, CR '� �rxt
<br /> k W (209024,t`7` 114 (8pt ) 4c�3- 1171 ( 8c"+B )7o3 - 7 } ^ ? (5Gr3 )_t£agcgG
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<br /> I T 05-1- E'10 A
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<br /> TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> t�� • received the abode indicated wastes in accordance with the requirement outlined in that authorization .
<br /> Print/Typ5 ,lame Signature Date
<br /> yr y � �s %�l r •
<br /> INS..
<br /> ORIGINAL
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