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R• MEDICALWASTEMANIFESTNIpNUMBER
<br /> -L Stericyclea IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .800024300 STANDARD 001 .p3.221wC:
<br /> Route # 706 - 15 CUSTOMER NO. 21132 MDTKOOOVTT
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATTN : Eric Crowley
<br /> I �TOKAY DIALYSIS- DAVITA 4*2016
<br /> 312 S FAIRMONTAVE 8/19/2022
<br /> LODi , CA 95240-3840 (2109) 369-5418
<br /> 6053303. 001
<br /> CUSTOMER NUMBER GENERATOR'S RE iSTRAT1oli tl
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<br /> 2A. DESCRIPTION OF WASTE tae CONTAINER TYPE 2C. No, OF 20, VOLUME
<br /> UN3291 , Regulated Medical Waste, n,03., T13144131o) Tp144Patti) TY1441nclnerate ) 44 Gal. e 0 ) 3
<br /> 6.2, PGII ♦ Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s., Tgg1 _(gb )_ _,_ TP15-(Path),• TY154Cherw 20 Gal . Tu (2 .7 CA)
<br /> 6.21 PGII Cu Ft.
<br /> CC UN3291 Regulated Medical Waste, n.o,s., TB49A1o ) TY49 .4Chemo ) T1494Indnerate ) 37 Gal . Tub (4 .9 Cu .}
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o•s., VAM3 ( BIo CV413 -(Chemo ) WX43415harm) 43 Gal . Tub (5 .T .)
<br /> Cu Fie
<br /> LU Z UNRegulated
<br /> Regulated Medical Waste, n,o.s., KB Gal . Corrugated BOX (4 .32 CUR .) Cu Ft.
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<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, 15131I Cu Ft,
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.21 PGII Cu FL
<br /> UN3291 Regulated Medical Waste, n,o,s.,
<br /> 6.2. PGII
<br /> Cu Ft.
<br /> got 1
<br /> 3. Generator's Certificstionl "1 hereby declare that the contents of this consignment are fully and accurately TOTALS16961 Cu Fto
<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 regulations"
<br /> IX
<br /> P Name I • Signature
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<br /> 4. TRANSPO ER .1 AD AE S: Phone N: 209)
<br /> encyc�e , enc . [� This Is a Through Shipment Applicable Permit Numbers: -
<br /> 7875 R A Brid ,,eford Rd . TS/OST 80
<br /> S Stockton , CA 95206
<br /> TRANSPORTER FICATi : Receipt of medical waste as descri ve. (Wily [,eez
<br /> Prinflfype Name ..,_... Signature Ae Data
<br /> ghetto 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<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 /> 8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> ; . Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATIOW Receipt of medical waste as described above,
<br /> Print/Typs Name , Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> rAGA, Designated F:nIAU
<br /> : 89, ARemate Facility: 8C, Alternate Facility: 8D. Alternate Facility:
<br /> J Stericycle , Itoclave) Stwofoycle , Inc , (incinerator) Sterlcycle , Inc . (Autoclave) Covants Marlon , Inc
<br /> Siegel
<br /> 7876 RA Bford Rd . 90 N , Foxboro Drive 2776 E , 26th St , 4850 Brookiake Road NE
<br /> Stockton , C206 North W Lake , UT $4054Vernon , CA 90066 Brooks, OR 97305
<br /> (209 )4 41 . .� .1Sr (801 )936- 1171 (866 )7834422 (505 ) 398-0$90
<br /> TS/OST80 AU.rOUCAVC D � 3A-448/JA-35 Pbrmlt # 364
<br /> TREATMENT FACIU rlify that 1 have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the cop p ibdib gg *astes in accordance with the requirement outlined in that authorization .
<br /> Print/Type Name Signature Date
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