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MEDICAL WASTE TRACKING FORM NUMBER
<br /> �* St@nC�/CI@' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -600�424.930o STANDARD MANIFEST 001 .03.21 •NOCA
<br /> ,7 Route #. 706 - 8 CUSTOMER N0. 21132 MDTKOOOPJ5
<br /> I . Generator's Name, Address and Telephone NumberATTN * Eric Crowley
<br /> II ii ii II `` I
<br /> 7"t3KAY rJIALYS1s" DAVITA #2016
<br /> 312 S FAIRMON'rAVE 6/17/2022
<br /> LODI , CA 95240-3840 (208) 368-5418
<br /> CusTOMER NumsER 6053303" 001 GENERATows REoiaTRATtoN rt
<br /> 2A. DESCRIPTION OF WASTE 20. CONTAINER TYPE 2C. Not OF 211). VOLUME
<br /> UN3291 , Regulated Medical Waste, n.o.s., TB14_ Blb CONTAINE
<br /> 6.2, PGII ( ) t TP14_(Path) TY14 -( itlCltll; rBtOj 44 GRI . Tub {5 . 9Cuftj Cj � , Cu Ft.
<br /> 62, PGII 91 Regulated Medical Waste, n,o.s„ T821 -(810 )._., _ TP15_(Path)._TY154Chemo ).. 20 Gal . Tui (2 .1 Cull ) cu Ft.
<br /> O
<br /> UN3291 9G1Regulated Medical Waste, n.o.s.,
<br /> 62TE3413_(810 ). TY496 (Chemo )^ T140411nelnerate } 37 Gal . Tu (4 .0 Cult .) Cu Ft.
<br /> Q
<br /> 6.2, 291 111311
<br /> Regulated Medical Waste, n .o,s„ W843481o) Ck 43 -(Chemo )_ 1X434Pha m ) 43 Gal . Tu (5 .700 .) Cu Ft,
<br /> W UN3291 Regulated Medical Waste, n.os„
<br /> IZ 621 PGII KR (Bib) Gal . Cornfgated Bax (.4 .32 Cu11 . ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6 2, PGII VYZTr t Cu Ft.
<br /> UN3291 Regulated Medical Waste, 11.0.s.,
<br /> 6.2, PGII Cu Ft,
<br /> UN3291 Regulated Medical Waste, n.o.s,, Cu Ft.
<br /> 6.2, PGII
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<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 It10 1vo L 6 7 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 transpo according to applicable International and national governmental regulations"
<br /> PrintecYT NameA (Skr Signature Date 2 2
<br /> 4. TRANSPORTER 1 ADDRESS: Phone ft: (209) 2944114
<br /> w Stericycle , Inc. . This is a Through Shipment Applicable Permit Numbers:
<br /> a o 7875 R A Bridgeford Rd . 'TWOST 8O
<br /> N Stockton , CA 95206
<br /> a� a TRANSPORTER fa&RTIFICATIONd Receipt of medical waste as describe ve.
<br /> a PrInUType Name UQA (2 `el (1 Signature iR (=ter'-""-- — Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone C
<br /> N Applicable Permit Numbers:
<br /> i INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/rype Name Signature Date
<br /> i, 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone 01
<br /> S Applicable Permit Numbers:
<br /> W
<br /> z a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br /> a � =
<br /> Printrrype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> } 8A. Designated Facility; 80. Alternate Fpciltty; 8C. Attamets Facility: 8D. Attemate Facility:
<br /> -t Sterlcycle , Inc . (Autoclave) Stericycle , Inc . (incinerator) Stericycie , Inc . (Autoclave) L ovanta Marlon , Inc
<br /> 7876 R A Brldgeford Rd , SON Foxboro Drive 2776 E . 26th St , 4860 Brooklz,lte Road NE
<br /> Stockton , CA 962013 North Salt Lalce , UT 84064 Vernon , CA 80068 Brooks, OR 97306
<br /> g$ 103 284411Q r
<br /> w � ( ) (801 ) 138- 1171 (8fi1t's )783 -7A22 (60x )393- 0880
<br /> TS/0ST 80 3AB 448/JA% 0'6 Perr-Nl* 384
<br /> Convanta Madon inc.
<br /> TREATMENT FACIL•IT,YrI•certify Oue I have been authorized by the applicable state agency to accept untreated medfdl�E;�W>� � ' q Woo
<br /> i it �,. i . , . , tt
<br /> 1- received the 06#,V?, Ihdtcated wastes In accordance with the requirement outlined in that authorization .
<br /> AU FOCUAVED
<br /> Printlrype Name Signature Date . Il 1 N 20
<br /> JUN 2 0 2022 .irf'r
<br /> • e rORIGINAL
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