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MEDICAL WASTE TRACKING FORM NUMBER
<br /> �9 Ster1 ycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .800-4249300 STANDARD MANIFESTOot •D3-21 •NocA i
<br /> R011.1101 703 - 15 CUSTOMER N0, 21132 MDT1fUClOrRXF
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> 11T rr : 1~ t : c C; giv1oyl flliI ! I Ill
<br /> Ti,� KAY U}AI` I SADA 111"A X 010 nil
<br /> 312 S FAICr' MONTAVE 7! •12J2022.
<br /> LOD17 CA95240w,2140 ( 209 ) 369-5418
<br /> 6053303,A001 ;
<br /> CUSTOMER NUMBER GENERATOn,s REGISTRATION N
<br /> 2A. DESCRIPTION OF WASTE 213, CONTAINERTYPE 20. Not OF 2Da VOLUME
<br /> UN3291 Regulated Medical Waste, n.os., _ -- , _ CONTA N
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<br /> MANAMA
<br /> 3. Generator's Certifications hereby declare that the contents of ails consignment are fully and accurately TOTALS r 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 transport according to applicable international and national governmental re lations"
<br /> Print Name t" Signature Date
<br /> 4. TRANSPORTER i ADDRESS: P ne f1:( 2 .1 ) 94 - 71111
<br /> `� 1 #; P1t f: lU , 1nC . This, is na Through 4;}1{}itilt: ltl A pitcable Permit Numbers;
<br /> po 787 :, RTS 13ridgeford nit . .1 �Oil
<br /> Stockton , CA 95200
<br /> a � TRANSPORTER C�T�IFrICATIQN : Receipt �tfinedtcal waste as describe t �
<br /> Print/Type Name Signature Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #0
<br /> N
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Print/Type Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: phone No
<br /> Applicable Permit Numbers:
<br /> W
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFIC;A'f10N : Receipt of medical waste as described above.
<br /> PdnMps Name Signature Date
<br /> 7. DISCR PA
<br /> LE1~€$
<br /> eA. slpnated Facility: �J I� 8B. Ak ate Fsclltly: 8C. Alternate Faclllty: 8D. Alternate Facility,$
<br /> wtcrlC cle , lrn_ . J t �la%{ _ Stena : , lfiv' , Inc# neratut _ rit•� e a
<br /> (I, } �} r ( l t f- l _ , lno . (autoclave) Co ✓anta Marion , Inc:
<br /> 4 7d75 A Elridger , 4i?c! 2Q2z 911 No F aeboro Drive 9775F Es 260) St, 41;50 Eroohlalte Road NE
<br /> LL > Stolt' tGn , CA 9 ;:205 Idortll � At taller; , UT 2t1 G5� Vernon , CA90u53 Eroolt .y, rtr' 073115
<br /> Z (209 221 - 71 r, (801 )9 8 - 9 .171 4 (3013 )7834422 (5115 ):393- 0390 I
<br /> W T4,i!,", ' � _ ' ` °fie :31a 4ll MAA 36 r
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<br /> TREATMENT FACILITY: I certify that I have een authorized by the applicable stats agency to accept untreated medical wastes and that I have
<br /> fes- received the above Indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type Name Signature Date
<br />
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