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MEDICAL WASTE TRACKING FORM NUMBER
<br /> St@i"IC�/� @� IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-4249300 STANDARD MANIFEST 001 .03.21 •NOCA
<br /> 'u I'it. ule it 7013 - '12 CUSTOMER NO, 21132 MD'fK00GQZ0
<br /> I . Generator's Name, Address and Telephone Number t f N'I' fATTN : Eric c.t o};�=1iy7 �€ 11 R 1111,
<br /> (� KAYi'IAt`( �� iS� DAVITA ##f01f31 � E E (� Ia 1 I19i� l ll ?! I41 '� II i` ? fidtil
<br /> 312 S FAIRiu1ONTAVE 7 :` If:022
<br /> LOU; CA95240- 3sr,- 0 ( 209) 369- 5418
<br /> . G053 ' 03- 001 •
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 28, , CONTAINERTYPE 2C. NO, OF 21D. VOLUME
<br /> UN3291 Regulated Medical Waste, n,O,S„ T 1 ;� ., I lU 1 '1 1 - c`!il"I T'Y� { =� - ( rlClrit� "cst� 411 Gal . Tub F 9N`AINE
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<br /> UN3291 Regulated Medical Waste, n.ox,, T13321 - BlD TP15_ Path T `f15- C'herllo 0. 0 tial . Tub- 2 7 Cuft .
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<br /> jX UN3291 Regulated Medical Waste, n.o.s., G.lg- i0 i Y4 a'- herno TM Q. Iridnei'•�ti »7 Gal , Tu 7 c1 . rl CUft,
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<br /> UN3291 Regulated Medical Waste, n,o,s,, ;f•vB4S ( 1:310 )_-T- C� �r % Sos{C.* i�el�ltr )_. 1A/, 4S[ ( Pha1Yri ) __ 43 Gal , TU (5 , 7Cuf. )
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<br /> W 62, PG1ilRepulatedMedlcalWaste, n.o.s., KR (Blo ) -, . . „__G :11 . Colelligate. d Box ( I . »:� CO . )
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<br /> Vr UN3291 Regulated Medical Waste, n.o,s.,
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<br /> UN3291 , Regulated Medical Waste, n,o.s„ Cu Ft.
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<br /> UN3291 , Regulated Medical Waste, n.o.s., Cu Ft,
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<br /> UN3291 Regulated Medical Waste, n.o.s„
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<br /> 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accuratelyTOTALS / 5 Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placard
<br /> are in all respects In proper cAidillon for transport according to applicable international and national nmentai
<br /> Printad/Typed Name 1 SI Date 7 h
<br /> 4. TRANSPbR1 one '7
<br /> { 0Ct} 2 �4 _
<br /> TER ADDRESS: Ph # :
<br /> GC rat4; i'ICjjCI �', , ? 11G . (� _ _ r b f '? •1 �->
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<br /> Thies is a Through `4111pttit tit Applicable Permit Numbers:
<br /> 7c; 70 R A Brid(jeford Inc{ . T�;Ir� ' T OCI
<br /> IL t. tockloli , CA 95206
<br /> o� z TRANSPORTER,CERTIFICATION : Receipt of medical waste as described above. /� j f j
<br /> Print/Type Name jvan- Co 111 Signature ""��n n Date ` L
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; Phone #:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER ! TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Prfntrrype Name Signature Date
<br /> 6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> wApplicable Permit Numbers,
<br /> S a INTERMEDIATE HANDLER ! TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> z � x
<br /> — PrinYType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> y 8A, Designated Facility: 813. Alternate Faciltiy: [] 80. Alternate Facility: 8D. Alternate Facility:
<br /> F.j S :_ ricyrole , Inc . (Autacb/ 0) StLtncylwll j , inc. . (lncineraltor) Ste(myole , Inc . (Autoclave) Covanta 'Marion , Inc,,
<br /> Q 7875 RA Bridgeford Rd . 90 N , Foxboro Drive 27 '15 E , 26th St , 4850 Brooldahe Woad NE
<br /> �•
<br /> w Stoohton , 5. A 1,1620 `i Float! 'y-'alt Lake , UT 80164 Vernon , CA Q0050 Ltrook„ OR 27306
<br /> w (201; ) 2IA -711d ( aI ) ur- 1371 (y0B )788 -7d22 ( 05 )^ 93 080tt
<br /> T`f05i G . i3tt-iId &J w8o' Permit 3GLf
<br /> TREATMEjy0. 1 &,Y�1 certify that 11 have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> i— received t�lfi{�ZffIYl ted wastes ip accordance with the requirement outlined in that authorization,
<br /> Print/Type N it Signature Dale
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