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MEDICAL WASTE TRACKING FORM NUMBER
<br /> G e Stericycle� IN CASE OF EMERGENCY CONTACT: CHEMTREC lvoSW424-M STANDARD MANIFEST 001 -03.21 •NOCA
<br /> Route #. 703 - 16 CUSTOMERNO, 21 / 32 MDTK060UQH
<br /> 1 . Generator's Name, Address and Telephone Number ff !! ## ff
<br /> ATAI
<br /> Eric Crowley
<br /> TC� KAY DALYStS- DAVIDAVITA ##2016
<br /> 312 S FAIRMONT AVE 0/9/2022
<br /> LODI , CA95240-3840 ; 1 ( 209) 369- 6410
<br /> 6053303. 001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATioN S
<br /> 2A, DESCRIPTION OF WASTE 284CONTAINER TYPE 2C. NO. OF 2D. VOLUME
<br /> UUN329G111 Regulated Medical Waste, n,o,s„ TB14 -(Sio ) TP14 - ( Path ) TY14-( incinerate ) 44 Gal . Ty
<br /> bCq r l
<br /> 642, P
<br /> t( Cu Ft,
<br /> 623291, Regulated Medical Waste, n.o.s., TF121 -(Bla )__.. TP '16-(Path ) TY15-( Chemo ) _,,,, 20 Gal . Tu (2 .7 Cult , )
<br /> Cu No
<br /> O UUN32291i1
<br /> Regulated Medical Waste, n.o,s„ TB49-(Bio )�_TY49-(Chemo ) T1494Incinerate ) 37 Gal , Tub (x.1 , 9 Cu . ) Cu Ft.
<br /> QUN3291 Regulated Medical Waste, n.o,s „ 'A11343LfiO Ghenio
<br /> 6.2, PGII -( ) CV11 (
<br /> 43 ) VVY,43-( Phammn ) 43 Gal . Tub (6 , rCu . ) Cu Ft,
<br /> W UN3291 Regulated Medical Waste, n,o,s., rf rR
<br /> Z 6.2. PGI, (Blo ) .,.„_,_haat . Corougated Box (4 . 32 Cuft. ) Cu Ft.
<br /> 621 22G1, Regulated Medical Waste, n.o,s.,
<br /> II Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o,s„
<br /> 6.2, PGiI Cu FI.
<br /> UN3291 Regulated Medical Waste, n,o,s„
<br /> 6.2, PGI, Cu Fi.
<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 6.2. PGII Cu Ft,
<br /> 3. Generator's Certifloatton : 01 hereby declare that the contents of this consignment are fully and accurately TOTALS ► 7t ' 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 regutati
<br /> Print Name C14 I �✓fr/! � ' S nature Dat � Q �
<br /> d. TRANSPORTER 1 ADDRESS: Phone #: ( 20) ZU44114
<br /> Stericycle , Inc . This iS a Through ShIP111113111. Applicable Permit Numbers:
<br /> 7875 R A Bridgeford Rd . TS/OST�80
<br /> Stockton , CA 95206
<br /> If TRANSPORTER QIF�ICATIO�loReceipt of medical waste as describeCd; '
<br /> Pdnt/Type Name Ak '7 Signature Date �Y
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone ff:
<br /> N 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 8 ! TRANSPORTER 3 ADDRESS: Phone H:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: ' Recelpt of medical waste as described above,
<br /> (_ PrinMpe Name Signature Date
<br /> Woo
<br /> 7e DISCREPANCY INDICATION
<br /> 8A, Do ilgriatood Facility. GALEA 89. Afte ate Faclllty: E) 8C. Afternate Facility: 80, Altemate Facility:
<br /> Ste icycle , Inc. NITQ04A 'ED Stenk vole , Inc. . (Incinerator) Sterioycle , inc . (Autoclave ) Govanta Marion , Inc
<br /> a 73 15 R A Bridgeford Rd , 00 N Foxboro Drive 2775 E , 28th St , 4850 Brooklake Road NE
<br /> u- Stc *ton , CA MOO � 02022 Norl Salt Lake , LIT HUM Vernon , CA 90068 Broolts, OR 97305
<br /> w (20 ) )294-7114 (201 38- 1171 (886 )7834422 (5015 )393 -0090
<br /> T5 Tn80 3A4 81JA-86 Permit # 384
<br /> U TREAT n authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> H received the above indicated wastes in accordance with the requirement outlined in that authorization ,
<br /> Print/Type Name Signature Date
<br /> ORIGINAL
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