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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 0.9, Stericycte! IN CASE OF EMERGENCY CONTACT: CHEIMTREC 14W4244= STANDARD MANIFEST 001 -03.21•N00A
<br /> Route A 706 -20 CUSTOMER No. 21132 MDTKOOOUGV
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATEricCrowley
<br /> DI
<br /> TOKAY DIIII IIIIIIiI III i Ii I N III IIIIIIii IIIIIII i IN illi III
<br /> ALYSIS- DAVtTA *2016
<br /> 312 S FAIRMONTAVE 8/5/2022
<br /> LODI , CA 95240-3840 • ' ho : (209) 369-5418
<br /> 6053303=001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION N
<br /> 2A. DESCRIPTION OF WASTE 213. CONTAINER TYPE 2C. NO, OF 20. VOLUME
<br /> 8U2329Ii Regulated Medical Waste, n.o,s., T814 -(810) TP144P �Ith) TY1441ricinerate) 44 Gal. g°(.l�
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s., TB214Blo ) TP15 Path) TY1 Whemo 20 Gal . Tu (2 .7 Cult .)
<br /> 8,2, PGII � ) Cu Ft.
<br /> lir p 6 23PG�I Regulated Medical Waste, n.o.s., TB49-(Bb ) TY494Chemo) T1494Indnerate) 37 Gal . Tub (4 .9 Cu .) Cu Fl.
<br /> Q UN3291
<br /> 2, PGI { Regulated Medical Waste, n.o.s., iNB43{Bio) CIM� 3=(Chemo) WX43 {Pharm) 43 Gal . Tub (5 . 7Cu .)
<br /> � Cu FI.
<br /> W UN3291 Regulated Medical Waste, n.o,s.,
<br /> Z 8.2 , 1`611KFt (BIo) Gil. Corrugated Box (4 .32 C R )
<br /> ICu Ft.
<br /> UN3291 Reguiated Medical Waste, n.o,s., ^
<br /> 6.21 PGII lU 1 Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s„
<br /> 8.2, PGI)
<br /> Cu Ft,
<br /> UN3291 Regulated Medical Waste, n.o.s,,
<br /> 6.21 PGI) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.2, PGII Ou Ft.
<br /> 3, Gerwrator's CertMeatlon: "I hereby declare that the contents of this consignment are fully and accurately TOTALS i► , ems Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and Iabeiled/placarded, and
<br /> are in all respects in proper condition for tran8 V according to applicable international and national governmental regulations" Q
<br /> Print Name t �,� ' ' - .. Signature
<br /> 4. TRANSPORTER 1 ADDRESS; Phone N; (209) 294.7114
<br /> SteriCyale , Ina . This is a Through Shipment Applicable Permit Numbers;
<br /> 7875 R A Bridyeford Rd . TWST 80
<br /> g Stockton , CA 95206
<br /> a TRANSPORTER FICATION : Receipt of medical waste as de s« ve. h
<br /> PdnUType Name '1` ah �in _ _ Signature (� ��(0 Date Q V
<br /> &0
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS;
<br /> Phone N ;
<br /> `V Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrinMpe Name Signature Date
<br /> S. 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 /> PdnVType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 8A signaled Facll :GALEA 88. emafe Facllky: ©BC. Alternate Facility. 80. Alternate FacHky:
<br /> ericycle , inc ��t�dCleve�0 Sh Icycle , Inc . (Incinerator) Stericycie , inc . (Autoclave) Coventa Marlon , Inc
<br /> MINES
<br /> 1 7 76 RA sri�g�o� ��i0 � z 90 . Foxboro Drive 2775 E , 26th St, 4850 Brooklake Road NE
<br /> 14L ckton , C li L No Sak Lake , UT 84054 Vernon , CA 90058 Brooks, OR 97305
<br /> ( 09 )2944114 (8 )936- 1171 (866 )783 -7422 (305)393-0890
<br /> OSTWJR ZIASMAoZIS Pirtl`tiltf 364
<br /> �TREA FiCI : ice t a an authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> 11000 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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