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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 40W;. Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 14004244M STANDARD MANIFEST 00103.21 •NOCA
<br /> Route #: 703 - 13STOMER N0, 21132 MDTK000T13P
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATEric Crowley
<br /> TC� tCAY DI CIALYSIS-DAVITA #2016
<br /> 312 S FAIRMQNTAVE 7/26/202
<br /> LOCI , CA 95240-3840 to ' ( 209) 369-5416
<br /> 6053303- 001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION N
<br /> 2A. DESCRIPTION OF WASTE 2e. CONTAINERTYPE 2C. Not OF 20. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o,s., CONTAINERS
<br /> 6,21 PGII TB14 - (B 'lo ) 7P14 - (Path ) TY14 -( Incinerate ) 44 al , Tub ( B . A eft) Cu Ft.
<br /> 6232PGiiReOulatedMedicalWaste, n.o.s., TB21 -(Bio ) TP16-(Path ) TY1 &( Cherno ) 20 Gal , Tub (2 .7 Cliff . )
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s„ Biom emo Tnnerate a . u . Cuff .
<br /> FFF 6,2, PGII TM ( �--TY49- Ch( � l4 � Id ) 37 Gal . Tb (4 ) Cu FL
<br /> 623PGIIRegulatedMedlcaiWasie, n,o.s„ VV1343-( Bio ) CV43-(Chemo )^WX43-( Phartrt ) 43 Gal . Tu �Wfd;lt Oro cu Fl,
<br /> W UN3291 Regulated Medical Waste, n.o,s,, KR B' ) e ( ) y
<br /> `Z ¢.z, PGII ( 10 Gal . Corrugated Bax 4 . 32 Cult. 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 /> 6.2, PGII Cu Ff:
<br /> UN3291 Regulated Medical Waste, n ,o.s. ,
<br /> 6.2, PGI) Cu Ft.
<br /> 6N3291 Regulated Medical Waste, n,o,s„
<br /> q Cu Ft.
<br /> 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ' I • 9 Cu FI.
<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 governmentj regulations"
<br /> XPrintsdMiped Name M � S ' si naturo Date 7 420 -.2Z.--
<br /> 4. TRANSPORTER 1 ADDRESScc : Phone N: ( 209) ?_7114
<br /> Sbancycle , Inc . This is a Thro gh Ship mentApplicabie Permit Numbers:
<br /> 7875 R A Bridneford Rd . TB/4ST 80
<br /> Stockton , CA 95206
<br /> a
<br /> TRANSPORTER CERTIFICATION : Receipt of medical waste as described abov
<br /> Prinl/TypeNoma w ` ' 11 IC4L MS Signature Date
<br /> 5. INTERMEDIATE HANDLER 2 1 TRANSPORTER 2 ADDRESS: Phone N:
<br /> N W
<br /> M+ Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> PdnVType Name Signature Date
<br /> 8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> aA. Designated Facility, El Sao Alternate Facility: E] 8C. Altsmate Faclllty: 8D. ANemate Facility:
<br /> Stericycle , Inc . (Autoclave Sterioyole , Inc . (Incinerate ) Stericycle , Inc , (Autoclave Covanta Marion , Inc
<br /> o it 7875 RA Eridgeford Rd. 90 N . Foxboro grive 2775 E . 26th St, 4350 Brooklake Road NE
<br /> Stackton , CA 96206 North Saft Lake, UT 840-5.1 Vernon , GA 90053 Brooks, OR 97305
<br /> w (209 )294w7114_ (301 )936 - 1171 (866)783-7422 (505 )393-0890
<br /> 'I'8/0517zdQ4toELI8E 3A4400A"38 Permit # 364
<br /> GALEA
<br /> n TREATMENT FAllffi" fir% that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F- received the abovindicated wastes in accordance with the requirement outlined in that authorization ,
<br /> Print/Type Name JUL' 2022 Signature Date
<br />
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