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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Steric cle' iN CASE OF ERGE Y : CHEMTREC 14W4244= STANDARD MANIFEST�001 .03.21 •NOCA
<br /> y t10ttfe CUSTOMER N0. 21132 MDTK00UW30
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATTN : Erie C ►'ovltlep
<br /> 7"OKAY DIALYSIS- I^ AVITA #2016
<br /> 312 S FAIRMONTAVF 8 /23/2022
<br /> LODI , CA 95240- 3840 •( 209) 369- 5418
<br /> 605330M01
<br /> CUSTOMER NUMBER GEN£RATOR'S REGISTRATION M
<br /> 2A. DESCRIPTION OF WASTE2a. CONTAINER TYPE 2C. NO, OF 2D• VOLUME
<br /> UN3291Regulated Medical Waste, n,o,s„ 1413 '14 . (13io ) trP •! 4 - ( Path ) TY14m ( lrlc:inerate) 44 Gal . Ti if a9
<br /> 6,21 PGII Cu Ft.
<br /> 6N3291 Regulated Medical Waste, n.o.s., T �2 .1_ (Blo )^ TP 15r ( Path )^_TY16-( Cherno )„_,_,_,_ 20 Gal . Tu (2 . 7 CI_tft . ) Cu Fi.
<br /> W 623Fa1IRegulatedMedicalWaste, n,o,s., TE 121 (Eio )� Cu_ TY49" (Chel'nO ), Tllg-( Incinerate ) 37 Gal . Tub (4 , 9 CLIPS ) Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s., vv!343_( Bio )7Z7 t`V1/:13-(Cherno )�WXa �(P} tarrn ) 43 Ga[ Tub ( 5 . 1 ) ! Z
<br /> • Cu FL
<br /> W UN3291 Regulated Medical Waste, n.os., Its (Blo) Csial . Corrugated Dox (41 . 32 Cuff . )
<br /> IZ 6.2Cu L
<br /> UN3291 Regulated Medical Waste, n.o,s„
<br /> 6.2, PGII kr%u QoCcoixiiaOCKC Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6,21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s„
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste,
<br /> 6.21 PGII Cu Ft.
<br /> 3, Generator's Certificationo "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► rJ 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 r tali
<br /> Pre Name ll (� g - ZeSAL
<br /> 4. TRANSPOLMERA ADpREgS: Phone N:
<br /> S enc clef Illc . 3� n in n Ti� �•Cij 11 c �'I " 'l' tZt
<br /> Its iv u o � � � v N � Applicable Permit Numbers;
<br /> 7075 R A Bhdye€ord Rei . TS/OST80
<br /> S Stockton , CA 95206
<br /> a TRANSPORT =" FICATION : ript of medical waste as described D ePr1nt/]ypa Name Signature at
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone f!:
<br /> a kr Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Prinl/rype Name Signature Date
<br /> M 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N;
<br /> cc cc Applicable Permit Numbers:
<br /> 33 INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt •ol medical waste as described above.
<br /> Print/Type Name Signature Data
<br /> 7. DISCREPANCY INDICATION
<br /> Designated FacIIRy: 99• Alternate Faclllty: BC, Altamate Facility: BD. A@amate Facility:
<br /> Steri t p l _ , terioyole , inc . (Incinerator) Ste6cycle , Inc . (Autoclave) Covanta Marion , Inc
<br /> v 1•RA 11 iJ . Forboro . Drive 2775 E , 28th St, 4850 Brooklake Road NE
<br /> Stockton , rA�LAYFMQ A ! rth Salt take , UT 84054 Vernon , CA 90058 Brooke, OR 07305
<br /> (209)294 -7114 (, 01 )g36 - 1171 (366 )783 -7422 (506 ) 393-08g0
<br /> Sf 8(AUG 2 4 ZOZ 3 -4480A-36 Permit # 304
<br /> At TR TMENT FACILITY: I certifythat I hav been authorized by the applicable state agency to accept untreated medlcal wastes and that I have
<br /> j rec ved ths�W1 n acc dance with the requirement outlined In that authorization ,
<br /> Prin a Signature Date
<br /> 1
<br /> ORIOINAL
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