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• MEDICAL WASTE TRACKING FORM NUMBER
<br /> Steric cls+ IN CASE OF EMERGENCY CONTACTS CHEMTREC 14K*�424-i = STANDARD MANIFEST OOl •03.21 •NOCA
<br /> • y FRctlie it 703 - Y5 CUSTOMERNO. 21132 MCITKO00Y66
<br /> 1 . Generator's Name, Address and Telephone Number ii (
<br /> ATT Eric Crovdu� y
<br /> TOK Y DIALYSISDAVI FA #9. 016
<br /> 312 q. FAIRN110 iTAVE 9/413/2022
<br /> LODIt CA 9521. 0- 3010 ( 200) 369. 5418
<br /> 60533tIM01
<br /> CUSTOMER NUMBER GENERATOR'S REO(STRATION N
<br /> 2A. DESCRIPTION OF WASTE 29, CONTAINERTYPE 2C, NO, OF 21D, VOLUME
<br /> UN3291 Regulated Medical Waste, n,o.s,, T 1314 - (81D )_�_TP 14-( Pati ) TY111i 0ricinerat_ )44 Gpl . T I `�IT�IINERtC C)
<br /> 6.21 PGII ( Cu Ft.
<br /> UN3291 , Regulated Medical Waste) n.o.s„ TE211 - (Bio )__- P1 (Path ) _ TY I5-( C• hemo )• _ __ 20GA . TLII ('� .7Gait . )
<br /> 6.2, PGII Cu Ft.
<br /> CC 623PGl1Regulated Medical Wask�, n.o,s„ TD } �' f,8io ) _ T '/� - ( G; � � rr� a )_�T #a �+ ( Incir�er �te ) ?7Gw) Tu4a ('d . 'QC. Lf . ) Cu Ft.
<br /> P4 UN3291 , Regulated Medical Waste, n.o.s., ,• i ,V, W S t� n , - Gal
<br /> 642, PGil < „� -( Eip )� _ { d+:-15 ( hemp ) V�. �{� -( Pharrtl ) 13 ' �1 TuU ( 5 , 7C ,a t . ) Ca Ft,
<br /> W UN3291 1) Regulated Medical Waste, n,o.s„ leP (Pip ) _ Goof . Cortugated Bov (4 , 32 Cuff . )
<br /> Cu Ft.
<br /> UN3291 , Regulated Medleal Waste, n.o,s ,,
<br /> 6.21 PGII T , Cu FL
<br /> UN3291 Regulated Medical Waste, ri.o.s.,
<br /> 6.2, Rd Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s„
<br /> 6.2, PGII Cu Ft,
<br /> UN3291 , Regulated Medical Waste, n.o,s.,
<br /> 6.21 PGII Cu Ft.
<br /> 3. Oeneretor's Cerlificatlon: 'I hereby declare that the contents of this consignment are fully and accurately TOTALS 10 524 Cu Ft,
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelledlplacarded, and
<br /> are in all respects in proper condition foLjrcmspO5jpqordIng to applicable International and national governme reguialiAdAA
<br /> a
<br /> Print Name , tura Date 1 3
<br /> 4. TRANSPOjfR 1 ADQRESS: Phone C ( 120U) 29440114
<br /> w, ci'tcyc a 11C . � FI7In in i Itt � � : 1i ISI +: it. ont
<br /> i a as it a u ,i1 I ' tai ruts Applicable PetmIt Numbar8:
<br /> 7875 R A Fiddoeford Rt:I .
<br /> a $� `:, tocklon , CA 95206
<br /> a rQC
<br /> TRANSPORTER CFEITIFICATIONO Receipt of medical waste as descr07
<br /> 1
<br /> ~ PrinbTypeName , ` signature / Date l�
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> N '
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER ITRANSPARTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Prinitrype Name Signature Date
<br /> n 6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone C
<br /> Applicable Permit Numbers:
<br /> s INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Recelpt of medical waste as described above.
<br /> Pdnllrype Name — Signature Dale
<br /> 7. DISCREPANCY INDICATION
<br /> RYAN USE
<br /> O"4"W (3C Fswn • a Attentate Feellityt SC. Af emate FociiNy: So. An.m s F.culty:
<br /> NJ Stericyeie , Inc . (ALltdcia61e) ; teri �ycie , Inc . (Incinerator) 5tericycle , ince (Autoclave) Collanta taiarian , Inc:
<br /> 1875 RI1 lCl.t Dej z 0 PI . Fo;L�orc Drive 2775 E . '26th St, 4660 BrooWake Load HE
<br /> LL stccktan , tLS
<br /> larch Salt Like , tPr 81) am Vernon , CA 00058 Drooko, OR 97335
<br /> (2 ! 9 )294 -718p1 )93fi - 197 '1 (8813 )780 -7422 (505 ) 398 - 0890
<br /> e iA - q �; YI iA-3U Pu- rrrfitW, 364
<br /> 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 /> PrinVType Name Signature Date
<br /> ORIGINAL
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