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MEDICAL. WASTE TRACKING FORM NUMBER
<br /> Stericyil: W IN CASE OF EMERGENCY CONTACT; CHEMTREC 14XXIc4244300 STANDARD MANIFEST 00i •03.21 •NDCA
<br /> Route * 7O6 -5CUSTOMER N0. 21132 MDTKOOOTRU
<br /> I . Generator's Name, Address and Telephone Number
<br /> ATEric Crowley
<br /> DI
<br /> TOKAY ALYSiS-DAVITA X1095
<br /> 392 S FAIRMONT AVE 71291202
<br /> LODI , CA95240- 3840 ( 209) 3591•-54 '18
<br /> 605330 -009
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION ff
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C4 NO, OF 2D, VOLUME •
<br /> UN3291 , Regulated Medical Waste, n.o.s., TB14 -(Bio ) TP14 •-( Path ) TY14" ( Incinerate ) 4Q p"MAT ufl�L
<br /> 6.2, PGII Cu FI.
<br /> UN3291 Regulated Medical Waste, n.o.s., TB21 _(BIo ) 7P15-(Fath ) TY15-( Chemo ) 20 Cal Tub (2 .7 C ft . )
<br /> Cu Fit
<br /> O UU232Pci1RRegulated Medical Waste, n.o,s•, TE49-(Blo ) 7Y49-(Chemo )_ TIQ941ricinerate ) 37 Cal . Tub (4 . CA , ) Cu Ft.
<br /> UU232911iRegulated Medical Waste, n.o.s., YVE34 &43io ) CVA3-(Chemo ) 1NX43-( Pharm ) 43 Gal . TU 5 . Cuft . 9 , a Cu Ft.
<br /> W UN3291Regulated Medical Waste, n.o.s., KR Blo Gal . Corrugated BOX 4 . 32 Cuft,
<br /> 6.2, PGII ( ) ( ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n•o.s,, � � 5 �Le r � *c9`10 S ! r �PGI33C�4f � 337
<br /> Cu Ft.
<br /> UN329f , Regulated Medical Waste, n,o,s•,
<br /> 6,21 PGII wwoo 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, PGIICu F10
<br /> 3. Generator's Certification : "I hereby declare that the contents of this corisignment are fully and accurately TOTAL$ ► , C FL
<br /> described above by the proper shipping name, and are classiI ed, marked and labelled/placarded, and
<br /> are In all respects in proper condition for trans t;rapplicab international and national govern vial regulati s
<br /> '' P Nam Signature BIS c�'' Date
<br /> 4. TRANSPORTER RES Phone 8: modwWas
<br /> 4114
<br /> erl rThis is a Through Ship M entAppiieabie Permit Numbers:
<br /> a 7875 R A Bridgeford Rd . TS/OST 80
<br /> Stockton , CA 95205
<br /> AMEND
<br /> CC TRANSPORTER CE IRTIFICATION: Receipt of medical waste as•descrribeild above.
<br /> PrinttType Name ?i�91I W 1 Signature Date
<br /> 6. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone It:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE H ER / T SPORTER IFICATION' Receipt of medt ste as described vat �.
<br /> Prinilry ame Signature pate r " r
<br /> B. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M
<br /> CC
<br /> Applicable Permit Numbers:
<br /> S INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: t t of medical waste as de cribed above.
<br /> Print/Type Name Signature Date
<br /> 7, DISCREPANCY INDICATION
<br /> Designated Facility; 8151. Agamete Faclllty: Ej EC. Alternate Facility. -OD. Attemata Facility;
<br /> JStencycle , Ino . (Autoclave Sterioycle , Inc. (Ina' nerato ) Stericycle , Ino . (Autoclavo. Covanta Marion , Inc
<br /> a 7875 RA Bridgeford Rd . 90 N . Foxboro Olive 2775 E . 26th St, 4860 Braoklake Road NE
<br /> u. Stoakton , CA 95206 North Salt Lake , HJT 8405e Vernon , CA 80058 Broriks, OR 97306
<br /> if
<br /> Z M (209 )294-7114 (801 )938- 1171 (868 )783- 7422 (506 ) 393- 0890
<br /> g . ..TS10ST,8Q , >, : 8A-4481JA-36 P rryyt 864
<br /> I— Oil f f = l ` n s 4& OBroCel,ako�RJ NEarlon i OR 97305
<br /> TREATMENT FACILITY: I certify that I have been authorized by the applicable slate agency to accept untreated medical WIF9 and that I have
<br /> F- received the above indicated wastes in acbordance with the requirement outlined in that authorization .
<br /> PrinVlype NamdWO 0 2 2022 AUG 2 ?_ 022
<br /> Signature Date
<br /> • (503) 393•g9p0
<br /> ). Y ; 110001653434
<br />
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