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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stencycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .8044249300 STANPARD MANIFEST 001 .03.21 -N00A
<br /> Rotssfle lP 703 '" `10 CUSTOMERNO. 21132 MDTKg00ZJJ
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> rN : Eric t.: ely
<br /> T
<br /> � 1CAY G1AL'f �� 1 �- UIt�DAkl1 "!7't 'i �01G �
<br /> 112 S FA1RMONTAVE 9 /27/2022
<br /> LOG1 , CA9524.0- 3END ( qq) 3qu�_ 5 1S
<br /> CUSTOMER NUMBER GENERATOR'S REOIBRRATION #
<br /> 2A, DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. Nos OF 2D. VOLUME
<br /> CONTAINERS
<br /> UN3291 Regulated
<br /> Regulated Medical Waste, n,o•s., T R •14 - (r; io ) TP14 - ( f SFh ) TY 1 'a-( I nolnerate ),•,_,_„_ 44 Gal . T, jb ( 5. 9 uft ) Cu Ft.
<br /> 6238G11Regulated Medical Waste, n.os., j R2 •1 -(Bio ) ^TPII5. (PaF1'i )_, T Y15-( G'hernu ) 20 Gal , Tut (2 .7 Cults ) Cu Ft
<br /> UN3291 Regulated Medical Waste, n,o.s., a T "4 t? - f; he 7 o 114 '9- In in?='rate 37 tial . TUU 4 . C, Cult )
<br /> p 6.2, PG11 t ) _ _ ( I )_ I ( ) —� ( ) Cu F6
<br /> sossss
<br /> !OR
<br /> UN3291 , Regulated Medical Waste, n.o.s., �ilR4 Rio CVVI �_ �. } , errlt7 M/X4 3 Phawri 13 Gal . Tub 5 , 7� ' .tl ,
<br /> 6.2, PGII ( )- ( �—. ( )--- • ( ) `/ �7 � U Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s., , hr
<br /> tZ 6.2 . PGH
<br /> ISI~'. ( 8ia ) r7al . �wai'l11C� atQil Ra:: ( <l . ".! C?tft . ) Cu Ft.
<br /> UN32911 Regulated Medical Waste, n.o.s.,
<br /> 6,21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s.,
<br /> 6.2, Pail
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.20 PG 11 Cu FL
<br /> UN3291 Regulated Medical Waste, n.0.s.,
<br /> 6.2, PGI !
<br /> Cu Ft,
<br /> 3. Generator's Certification : "I hereby declare that the contents of this consignment are fully and accurately TOTALS / Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/ptacarded, and
<br /> are In all respecls In proper condition for transport according to applicable International and national governmental regulations" p
<br /> Print Name SI net Data Cie 0 a r
<br /> 4. TRANSPORTER 1 ADDRESS: Phone if: ( 209 ) 294JIlef
<br /> stel'lcycle ) 111G . r� T hiS i `.; a ThrOLlg1i Applicable Permit Numbers:
<br /> 7875 R A 13ric1cgeford Rds TS/05; T N
<br /> X ° `31oi ttton , CA 95206
<br /> cc Z TRANSPORTER FICAT/IIO�NJ: Receipt of medical waste as descri d e. j(//� , y 120�
<br /> Print/rype Namet'lQ/t Cd t)Is Signature i % rf7 G�7�! Lam- -- DateyT / !G
<br /> S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone M:
<br /> a Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medicai waste as described above.
<br /> loss PrInVType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 8A. 0**WMI 1 fWurvE U 88. Aftemals Facility: ❑ 8C. Akemate Facility: 8D. Attemate Facility:
<br /> osmosis :6V V ()toclave ) SCaricyole , Eno , (Inuineratrr) Cteri :yole , Inc. . (.�:ubaclave) I avanta l ,iarian , Inc
<br /> 7876 RA Bridpeford R(.i :;O.p 20 } ! . Foxboro 06lie 27/ 5 E ) 261h St , 4 86 0 Droo Wake moat} NE
<br /> sms�'- = ut . QQ 812 North Fait LakE , U T 4054 Vernon , CA 90053 Droolc �, OR s7"06
<br /> w , t (866 ) 783- 7122 (505 )? 08- 0300
<br /> iSlG T ° 0 3AA4O/JA- a5 Perm? t it 964
<br /> cc a TR 1 t I have been authorized by the appilcable state agency to accept untreated medical wastes and that I have
<br /> imT6c%Ived the above indicated wastes In accordance with the requirement outlined in that authorization .
<br /> PrinMpe Name Signature Date
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