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MEDICAL WASTE TRACKING FORM NUMBER
<br /> �i e� Stericyclef IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800 42"300 STANDARD MANIFEST 00i -03.21 •N00A
<br /> ' Roule g 703 -20 CUSTOMER NOe21132 tv1DTK000XFW
<br /> I . Generator's Name, Address and Telephone Number
<br /> ATTN : uric Crowley 111CNIlil4l 111 l t II III it i 41 I�! lel elf I I (
<br /> TQKA`f t.IIALYsIts- C1AWITA #2016
<br /> 312 S FAIRMONTA IF 0/6/2024"J
<br /> LORI , CA95240- 3343 ( 209) 36M41 8
<br /> CUSTOMER NUMeEq C �} .ti33 � 3-I� 0 GENERATOR'S REGISTRATION N
<br /> 2A. DESCRIPTION OF WASTE 26, CONTAINER TYPE 2C, NO. OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., t CONTAINERS
<br /> 6.2, PGII TB14 - (Bio ) TPU ( Pain ) TY14 -( 1 nolnerate ),M__,_- 44 Dal , T ab ( a . E(Cuft) Cu Ft.
<br /> Sim
<br /> 623 PGII 91 Regulated Medical Waste, n.o.s„ T13421 - (Bio ) TPI13-(Path )„ T11115-( Cherno )„_. 20 Go) . TLI 1 (2 .7 Cuft . ) Cu Ft.
<br /> 0 6.23 PGIIRepulatedMedlcalWaste, n.o,s„ T1 40- (Bio ) TY49� (Cherno � _}' 140-( Incinerate ) 37 C-Ial Tub (4 , 0 Ct ft. ) Cu Ft.
<br /> 623291 Regulated Medical Waste, n.o.s., 1IN/134 Bfo CV11E C, i� Grno WX4 ?,-( Fhatt�t 43 Coal T�_Ib 5 . r _ _t t . )
<br /> 6.z, PGI) )MAN ( )...._.._. ) ( . Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n•o.s•,
<br /> IZ 662, PGli }% R_,_, (Elo ) Gal . Corrugated Box (4 . 3Gi
<br /> 2 ft . ) 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 /> 6.2, PGII 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 /> 6.2, PGII Cu Ft.
<br /> 3. Generator's Certification ; 41 hereby declare that the contents of this consignment are fully and accurately TOTALS 1110oj 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 trankport according to applicable international and national goveim
<br /> guiatione." / �i
<br /> Print Name " " - ' " " � SI ature � Date `'r%� l
<br /> 4. TRANSPORTER 1 ADDRESS; Phone ll : ( 200) 294 .7114
<br /> stericycle , 11c ,1
<br /> �� t � This is a -fl� rx� tlyll �I1ipnik: rtt Applicable Permit Numbers,
<br /> a 7875 R A Bric} c efortt Rd . 1'•ti/v _� T tJ0
<br /> V) Stockton , CA 95200
<br /> C6 TRANSPORTERZWFICATI ecelpt of medical waste as described
<br /> Printrrype Name cley Signature Date
<br /> S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; Phone M;
<br /> C4 Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> °rintlrype Name Signature Date
<br /> 6. INTL EDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS; Phone N.
<br /> °C Applicable Permit Numbers;
<br /> INTERMEDIATE HAAMLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/iype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> ! OA. Dadgnstod Facility: 09. Alttmte Fsclltty: aC. Alternate Facility, El t1D, Akemtte Facility:
<br /> VSiwricy ale , Ir l a Q v��) 5t? ria;1c . Ino . (Incinerator) Steric'ycle , ( no . (Autoclave) Covanta Marion , [ no
<br /> 4 7275 iW�h� eF_ t 90 N . Forbu, ro C)&L2 2775 E . 28th St, 4060 Drooklake Road NE
<br /> Stockton , CA 06200 North Salt Larle , UT 84064 Vernon , CA 90069 Brooks, OR 07305
<br /> W (' 09 ) 294 - 7114 (801 )938 - 1 .171 ' , (8158 )7834422 (506p300890T5/L7TSt� 3A-4'tL1fJ� - 9B
<br /> Q t ` Frrlrlit # 984
<br /> TREATMENT FACILITY: I certify that 1 have been authorized by ithe applicable state agency to accept untreated medical wastes and that I have
<br /> I— received the above indicated wastes in accordance with the requ'its ment outlined In that authorization ,
<br /> Print/Type Name Signature 1 Date
<br />
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