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<br /> ter. _ MEDICAL WASTE TRACKING FORM NUMBER
<br /> .;0L Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 14HO4244M STANDARD MANIFEST 001 -03.21 -NOCA
<br /> Route 1tt 700 -89 CUSTOMER No. 21132 , IVIDTI (000 `. U2
<br /> 1 . Generator's Name, Address and Telephone Number 1 �n
<br /> IIT TN : CI'it: Croviljy roo
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<br /> CUSTOMER NUMBER GENERATOR's REGISTRATION N
<br /> 2A. DESCRIPTION OF WASTE 2B• CONTAINER TYPE 20. NO, OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n,os„ ; a T 7 _ ' r , » • r "TAI E
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<br /> UN3291 Regulated Medical Waste, n.o.s., T C2 'i -(BIrj ). TI 1 �i- (F=` •_ th ) _ Pill5- rchErrlo ) 20 Gni . (; 7 lift . )
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<br /> W UN3291 Regulated Medical Waste, n,o,s., 1 L3 # "- ( [ ' o w _ _ I 'i/t ?- ( Cl i ? tilt I I ' rlf"r:.lt :arGte ° j Gall
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<br /> UN3291 Regulated Medical Waste, n.o.s, , , , r�.:jSoJF,is ) µ » 0jivi3» (ChernC, b1/ 'rd :W..(PhaIY101 __� ai r` s1 . Iu � ( r . 7r'ttit . )
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<br /> W UN3291 Regulated Medical Waste, n.o.s., r, , ^ 'i r; i»
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<br /> 3. Generator's Certification: of hereby declare that the contents of this consignment are fully and accurately TOTALS I► 41Y7 . Cu Ftt
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br /> are in all respects in proper conjditipjzfoor 1ranSpnaccording to applicable International and national governmental regulations"
<br /> XPrintectotrypecINameSignature
<br /> 4. TRANSPORTER 1 ADDRESS: Phone : ( 209) 29941•_
<br /> stet W f dev Inc * � TIIi s lus a TIVOLl (14l Shi }) illellt A cable Permit Numbers:
<br /> Stockton , CA 95206
<br /> a � TRANSPORTER CFICATIQN : Receipt of medical waste as describe ve.
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<br /> Print/Type Name i Signature Date
<br /> 6. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone f«:
<br /> N Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Printrrype Name Signature Date
<br /> M 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone Nt
<br /> Applicable Permit Numbers:
<br /> S INTERMEDIATE HANDLER ( TRANSPORTER CERTIFICATION . Receipt of medical waste as described above.
<br /> 2
<br /> Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> } 8A. Designated Facility: 8B. Alternate Facility: E] 8C. Altemats Facility: _ , A
<br /> 8DRamata Facility:
<br /> } E17t2riosycl '} , In _ . ( Arst �cl �ve ) ytrric�f.le , (incir�c, ratYr) 8tr5ric.yole , Irna . f�.utocicdel C? vLntz, f.laarion , int
<br /> 75 R r1 E3ridgeford Pd . 90 N . Foxboro [Drive 277 E . 20t1h =, t , 40%0 i + raGftlA9 Rclau PJr
<br /> W `' tocahtol, CA 9520Pi Nortft Salt LakEa , UT /133606/1 Vernon, CA 00068 E?ioGls:;, OR x' 7305
<br /> z ' Cly? 2 'J # 7 'f 14 mil} f c,^ f 's7f
<br /> 2i vlt_�'i t'L LTi�f�1 -i l .l � - rit�. tl'} f i/t: ' t1 F enTiil is at6 4
<br /> oPitTREATMEI i�FACILITYsI�ertify that (' have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> 1- received the above indicated wastes In• accordance with the requirement outlined In that authorization .tt
<br /> Print/TypeNaw L 10 ZU Z Signature Date
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<br /> ORIGINAL
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