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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Owe StericCIe! IN CASE OF MERGE Y CQ CNEMTREC� 1 80G 424-0300 STANDARD MANIFEST 001 •03.2t •NO0A
<br /> + OL1tL' 1 CUSTOMER NO, 21132 t`ODTKOOMP
<br /> 1 . Generator's Name, Address and Telephone Number I 1 ( f f p
<br /> F'1TTN : Eric rowley
<br /> •1'OKl•1Y IiRLl' RIS- DA'J ! T/ ;W1016
<br /> ", 12 FAIRMONT AVE 9 /9/2022
<br /> LODI , CA95240w*3840 ( 209) 369- 51 10
<br /> r0 323103- 001
<br /> CUSTOMER NUMBER GENERATOR'S RecuammoN M
<br /> 2A. DESCRIPTION OF WASTE 20, CONTAINER TYPE 20. NO, OF 2Ds VOLUME
<br /> UN3291 Regulated Medical Waste, No.s., T B14 -(Bio ) TP14• ( Psth ) T'ei4 -( incinerate ) 44 Gal . T iu� � Ill P)6.2, PGIi Cu Fte
<br /> UN3 91 Regulated Medical Waste, n,o,s„ T1321 —(Bio )........„_„TP15- (Path )�,_TY15-( Chemo ) •,.-,-,_•„ 20 Gal . TLt (2 .7 Cuff . )
<br /> Cu Ft,
<br /> a UN3291 Regulated Medical Wastg, n.o,s„ TBdP.I-(Bic ) TY4Ic Chemo T1493 Incinewrate 7 Gal Tub 4 . '7 CL ft .
<br /> UN3 91 � Regulated Medical Waste, n.o.s•, irA31 � �'t
<br /> -( Ctjo )- �L\��1 - (l 1ie1713i ) _ __V1/ )13-( PhaRi1 ) - 4 , Ca at TLIb ( Co . f ' LI , ) �
<br /> CU FL
<br /> W UN3291 Regulated Medical Waste, n,o,s., { � P ( jp ) C; a{ C tyl IlJgated ADX ( 4 . ',2 C USC, )
<br /> IZ 6.2, PGI ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, mo,s„
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s.,
<br /> 611 PGIi Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s.,
<br /> 6,21 PGII n u Ft.
<br /> 3, Generator's Certification : "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► 2
<br /> v 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 toapplicable International and national governmental regulations”
<br /> PrintName 4 14e.4f 4 ,r I Signature , Date kq 7L
<br /> WNW
<br /> 4. R
<br /> TRANSPO EADD�RESS Phone N: Lw ) r - 4114 1
<br /> tCI,�C�( (; 10 , 1t1C . This 10 %A ThrOLIgh ShIP1111CIlt APPlicablePermit Numt?e _ .
<br /> 787b R A Brldgefort:I Rtt . 1 4ifU`; f- 01]
<br /> g Stockton , CA 95206
<br /> a TRANSPORTER TiFICATiQN: R ` eipl of medical waste as described
<br /> Pdn Name L Signature ` --
<br /> VTyF>e 9 Date 1
<br /> Be INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> a Applicable Permit Numbers:
<br /> I
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Printrrype Name Signature Date
<br /> BeNEED
<br /> INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone k:
<br /> Applicable Permit Numbers:
<br /> W
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> ^ Prinilfype 'Name - - - Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> BA. Dnlynst� F + � � Be AtNrrraM FsctlHy: llC. AFtsmsh Facility,
<br /> So, Altemats Fsclllty:
<br /> Meet rlCyu. c , t _ . �nUT ? CIBy�?) �•ti;rjG fC {A , Inc , (InClnapat4r) CCG�f1G� GI ? , Inc, . (r1 �dtOGI3\� ?) �_;r?V8nt3 }!lc� tlCil , Inc
<br /> U40 if
<br /> 7 `46 RA i idc ef�r ?? 0 N . Foxboro Drive 2775 E , 16th St, 4650 Etrooldake Road NE
<br /> u. Bh c {tt ? 1' , gCY�il Norti) Salt Laker HJT 840511 Vernon , CA 90058 Drooks, ORQ7305
<br /> � ��uj
<br /> (1019 )29A -l1 i4 (3gi ) 338 - 1171 (888 )73;' • 74 ? 1 • (;SG51393 - r$ 9Q
<br /> TS/�] 7 t7 a `AA48"VJA- 38 Permit # 90 i
<br /> T : I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> 10111 received the above Indicated wastes in accordance with the requirement outlined in that authorization ,
<br /> PrinVType Name Signature Data
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<br /> ORIGINAL
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