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MEDICAL WASTE TRACKING FORM NUMBER
<br /> I3� Stericycfe IN CASE,OF EMERGENCY CONTACT' CHEMTREC 1 .8004424w9300 STANDARD MANIFEST 00lm03.21*N0CA
<br /> CUSTOMER No. 21132 MDTK000XOO
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> A ! TN : Eric C: rorsy+ layI � ll � �
<br /> 1-CIKAY G{AL'rS { S.. DAVI `{",t #2016
<br /> 312 S FAIRrvlONTAVE 61212022
<br /> LODI , CA 95240- 3840 ( 209) 369-5418 �
<br /> 6053303- Orli
<br /> CUSTOMER NUMBER QENEfTAT011'6 REQWRAT" A
<br /> 2A. DESCRIPTION OF WASTE 219, CONTAINER TYPE 20. NO. OF 2D. VOLUME ,
<br /> UN3291 Regutated Med(cal Waste, n.o.s. _ CONTAINE a
<br /> 6.2, PGII TE, 14 -(BiDTf' t . ( 4' ati ' ) TY94 -( Incinerate) c14 Gal . T R, ( a .1? G ! ) Cu Ft.
<br /> 623PG1I29RegulatedMedlcalWaste, n.o.s., 11332 _1 Pal 5- (F -3ffi ),,,•,,,m,mMTY '15-( Cherrlo ) 20 Gal . TU (2 . 7 C' Glft . ) Cp Ft.
<br /> 6.2. P6 Regulated Medical Waste, n.o,s., TP49- Elo TY4a- C-'herrjo ) T14p- incinerate 37 Gal Tub 4 . 9 CL fE.
<br /> FFF 6.2, PGII ( ) ( ( ) ( ) Cu Ft.
<br /> 623pGIIRegulatedMedicaiWaste, n.o.s., \ 1t1ic13-( B'ic )_ _C:V1F1u-(Cherno ) VdX4 -( 1' hanrl )_ _ 43Cral T�lla ( 5 . , ' • �_It . Cu Ft.
<br /> W UN3291 , Regulated Medical Waste, n,o,6., KR (Bio Gal Collmu ated Bo ; 4 ,.•L Gift. Cu Ft.
<br /> 6,2, PGII ) � " ( ° )
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 62, PGI { Cu Ff.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Fl.
<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 QU
<br /> Fla
<br /> 3. Generator'! Certification' "I hereby declare that the contends 01 this Conoignmer't Are fully and aoeuretety TOTALS lop , Cu Ff.
<br /> described strove by the proper shipping name, and are dassined, pac{caped, marked and labelledrplacarded, and
<br /> are In all respdcts In proper eondh:on nor trap according to applicable international and national governmental regulations"
<br /> D&M �r
<br /> 4, TRANSPORTER 1 ADDRESS; Phone M: ( 209) 2 J4 -7114
<br /> {i ti; { c, tlC1JCIG , Inc * T ITIS t8 i3 I11190 ( Ig {1 �3 { 11 {? Illefflt Applicable Permit Numbare:
<br /> 7u75 R A Bride ford Rd . TS/0ST 80
<br /> Stoo .klon , CA 35206
<br /> Iowa
<br /> CL TRANSPORTERFMFICAT110tj:{ Receipt of medics! wasteas PrinI/Type Narr'a � d r, Signature Date
<br /> i $. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; Phone 4;
<br /> Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical owls as described above.
<br /> PdnViype Name Signature Date
<br /> 8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone Mi
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Recelpt of medical welts as described above.
<br /> PrinVrype Name Signature Date
<br /> 7, DISCREPANCY INDICATION
<br /> it8A Dedgnstrd Feditty: saw Aflsrnoo FIllty: 11x7, Aleamats Fadltty; W. A'Wnatt, Fsdlity:
<br /> Steric^gale , Inc . (.Autocla se) �tericycl� , Inn. . (incinerator) Stericycle , Inc , (Autoclave) C:ovar'ta Marion . Inc
<br /> 4 7817SEYA ( 6' far72rg Rd . 90 NO ' Foxboro • Drive 2176 E. . 26th St , 4E150 Drookloke Read NE
<br /> Stockton , CA 95200 North SaltLakerill" 84051 Vernon , CA X90058 SrooU�, CR 97'305
<br /> (: -7 i 14 { 80 '1 )'336- 1 '171 (360 )7334422 (605)393- 0390
<br /> TSlCaBT 61J coA:�i4 /JA- std Permit r 0164
<br /> 1
<br /> pit TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical Wastes and that I have
<br /> ►- received the above Indicated wastes in accordance with the requirement outlined In that authorization.
<br /> Print/Type Name Signature Date
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