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j MEDICAL WASTE TRACKING FORM NUMBER
<br /> oCle Stericycle• IN CASE OF EMERGENCY CONTACT: CNEMTREC 140064244M STANDARD MANIFEST 001 .03.21 •NOCA
<br /> Route # 706 - 5 CUSTOMER N0, 21 / 32 MDTKOOOV4Z
<br /> I . Generator's Name , Address and Telephone Number
<br /> ATEric Crowley
<br /> T€ KAY DIALYwtS-DAVITA
<br /> #�201G
<br /> 312 S FAIRMDNTAVE 8/12/2072
<br /> LODI , CA95240- 540 ( 209) 369-5418
<br /> 61353303 001
<br /> CUSTOMER NUMBER GENERATOR•s REc asTRAmN 0
<br /> 2A. DESCRIPTION OF WASTE 2e• CONTAINER TYPE 2C, NO. OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., TBW(Bio ) TP14 -( Path ) TY14 -( Incinerate ) 44 Gal . T 'bc( Md ERS
<br /> �3
<br /> • Cu Fit
<br /> UN3291 Regulated Medical Waste, n.o,s.,6,21 PGJJ TE?21 _ Bio TP15- Path 1"Y16J- Chemo ,_,_. 20 Gal , Tu 2 .7 Cuftt .
<br /> IX F UN3291 Regulated Medical Waste, n,o.s., T840+ Bio ) _ ;rY4 ,,o ( ) (Chert? T149 Incinerate 37 Gal . Tub (4 . 9 Cu t. )
<br /> FFFF 62, PGII ( --�— Cu Ft.
<br /> 62Regulated Medical Waste, n.o.s.,
<br /> , PGIiYVS43-( Bio ) C%q- Orm(Chemo ).WX4Or-( Phan ) 43 Gal . Tub ( v . 7Cu . )
<br /> Cu Ft.
<br /> W623PGII Regulated Medical Waste, n.o.s., KRB ( Bio ) Gal Coriugated Bax (4 , 32 Cult. ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.21 Pall Cu Fit
<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, PGII 4 Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGiI 4Cu Fit
<br /> 3. Generator's Certification; "I hereby declare that the contents of this oonsignment are fully and accurately TOTALS �.JJ • Cu Ftt
<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 f �r iir�a/n�spo/rt ing to applicable International and national governmental re Ions" �•',�r
<br /> P Name ' v �' Signature Date
<br /> A. 7RANSPO`QjER .i ADQRE�S: Phone M.
<br /> a RrICyC C , 17c . This IN a Through ihlpmu t pplicable Permit Numbers;
<br /> 7875 R A Brldgeford Rd . TB/�S+ T 80
<br /> Stockton , CA 95206
<br /> a � TRANSPORTER 9CATIO/"elpi of medicai waste as clescribec[AbgWo
<br /> t..�Q � � f G
<br /> Prini/Type Name n Signature �
<br /> � � K Date
<br /> ., 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; Phone M.
<br /> N
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PdnVTyps Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 ! TRANSPORTER 3 ADDRESS; Phone x;
<br /> Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrIntJType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> eA. Ignited Fae111 AN ELI
<br /> ate Facility; ❑ tic. Alternate Facility, So. Attemeb Facility,
<br /> S ricycle , Incpp� cle , Inc . (Incinerator) Stericycle , Inc . (Autoclave) C-ovanta Marlon , ino
<br /> a 7 75 f ;A E+ridg'e o`f ' r� 0Foxboro Drive 2775 E . 26th St , 4850 Brooklake road 19E
<br /> u's S DoktOrS CA���� 1�1 0 Salt Crake , UT 84064 Vernon , CA 90058 Brooks, OR 87305
<br /> (� ] 9 )29,=71 f 6 ZQz36- 1171 (868 )783- 7422 (505 )393 -0890
<br /> T l08T$0 8/JA`Fk 6 Permit # 364
<br /> TRE N jj an authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> I" receive tea v with the requirement outlined in that authorization ,
<br /> Pdntrrype Name Signature Date
<br />
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