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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 0i i9 Stencycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 14= 424-9300 STANDARD MANIFEST 001 .03.21•NDCA
<br /> Rotlte #. 703 -9 CUSTOMER N0. 21132 MDTKOOOOFA
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATTN : Eric Crawley
<br /> TCIKAY DlALYSIS�DAVlTA #2016
<br /> 312 5 FAIRMONTAVE 6 /7/2022
<br /> LODI , CA 95210- 3840 (209) 389-5418
<br /> CUSTOMER NUMBER 6053303- 001 GENERATUR'S REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 29. CONTAINER TYPE 2C. NO, OF 213. VOLUME
<br /> 6 23PGII Regulated Medical Waste, n.o.s., Tp144BIo)�TP14 -(Path) TY 144 Incinerate) 44 Gal . Tub (91uW1
<br /> Cu Ft.
<br /> 623PG11 Regulated Medicai Waste, n.o,s., TB21 -(810 )� TP15 -(F3th), _ TY15{Ghemo ),_.. 20 Gal . Tub (2 .7 Cuft ) Cu Ft.
<br /> CC
<br /> 6.22,, PGII ) ( )_URegulated Medical Waste, n,o.s., TB494810TY4 0 - Chemo T1494Inoinera1e) 37 Gal . Tu (4 .g Cuft .
<br /> PGI ) Cu F1.
<br /> UN3291
<br /> Regulated Medical Waste, n.o.s„ kNM434BIo) C1N43 .(Chemo) M43-(Pharm) 43 Gal . Tu ( 5 .7Cuft .) Cu Ft.
<br /> W UN3291 , Regulated Medical Waste, n.o.s.,
<br /> IZ 642r PSI) KR ( Bio) Gal . Corrugated Box (4 .32 Cuft .)
<br /> Cur Fr.
<br /> UN3291 Regulated Medical Waste, mos.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6,21 All Cu Ft.
<br /> UN329i 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 /> 3. Generator's Certification: Of hereby declare that the contents of this consignment are fully and accurately TOTALS 1111a l I 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 applicable international and national governmental regulations"
<br /> r r
<br /> Printed/Typed Namo tLA
<br /> ` Signature acis Date
<br /> 4. TRANSPORTER f ADDRESS: Phone (209) 294 "7114
<br /> Sterlcycle , Inc , This Is a Through Shipment Applicable Permit Numbers:
<br /> �
<br /> S 1875 R A Sridgef'ard Rd . TS/OST- 80
<br /> 2 R Stockton , CA 95206
<br /> n°C Z TRANSPORTER r �TIFiCATIO }Fi/yeceipt of medical waste as descn ve.
<br /> ~ VCzAn �- " ` � ''t Signatures* �f*Yt ��---�_ Date adAP ! 49 .`
<br /> Print/Type Name
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> Applicable Permit Numbers:
<br /> Uj
<br /> i
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> M 6. INTERMEDIATE HANDLtR 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> Applicable Permit Numbers:
<br /> W
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> 4c
<br /> � — PrinUrype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> BA, Designated Facility: 88. ARemate Faciltty: ❑ 8C. Aftemate Facllityo ❑ BD. Alternate Facility:
<br /> iedycle . Inc . (Autotzlave) Sterlcycle , Inc , (Incinerator) Sterlcycle , Inc. (Autoclave) Covanta Marlon , Inc
<br /> a 7875 RA Bridgeford Rd . 90 W Foxboro Drive 2776 E , 213th St, 4850 Brooklake Road NE
<br /> I Stockton , CA 95206 North Salt Lake , UT 84054 Vernon, CA 90058 Brooks, OR 97305
<br /> I z W9 ( 209 ) 2944114 (601 )936 - 1171 (866 )783-7422 (505 ) 393 -0890
<br /> 2 TSIOST 80 3A448/JA-36 Permit # 864
<br /> Lu TREATMENVOWE bl certify that have been authorized by the applicable state agency to accept untreated medical wastes and that f have
<br /> ►— received ttAl G6�fatlr'ted wastes i accordance with the requirement outlined in that authorization .
<br /> Printlrype N Signature Dale
<br /> E
<br /> ORIGINAL - - - - - - - - - -
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