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<br /> m MEDICAL WASTE TRACKING FORM NUMBER
<br /> -•�� Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 � 800-424-9300 STANDARD MANIFEST 001 .03.21 •NOCA
<br /> nOLIte �: 7Or _ r CUSTOMER No, 21132 MDTI DOOL 9K
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ovvley
<br /> TOKAY 0IAL.Y •SI ,'D/11.17Ag.?nj ; � 1 � � ;t� I � I I �
<br /> 312 S FAIFti1IONTAVE 9 /23/2022
<br /> LODI , CA 95;?j1CI- 384D ( 209) 23 G5- 5 . 13
<br /> 6D531303 - 801
<br /> CUSTOMER NUMBER GENERATOR's REGISTRATION N
<br /> 2A, DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. N04 OF 2D, VOLUME
<br /> UN3291 Regulated Medical Waste, n.o,s., _ , , d � , ; ^ CONTAINERS
<br /> 6.2, PGII T 01 # (Bolo ) TF 1 ( Path ) n i # ( Incinerate ) __ __ 44 Gal . TI b ( 5 , f� ult) Cu Ft,
<br /> 611
<br /> UN3291 Regulated
<br /> Regulated Medical Waste, noels., `E42 ` 4910 ) TTP 15 - (Path )._TY1 &(, Chen io } 20 Gal . Tut ( .7 GLffi . ) Cu Ft.
<br /> CC UN3291 Regulated Medical Waste, n.o.s., B10 `i � 4Q,It Chenio ) Tid2- lncinet•atr ?• 7 Gal . Tub 4 , 0 Cu
<br /> I �? 1, li_ Cu Ft.
<br /> 6,2, PGII ( 1...._ .-... l - ( ) ( )
<br /> Q UN3291 Regulated Medical Waste, n.o.s., Vv254 ,' - Bio GViA 3- �'�` 11e1" 0 \1%0rfKd oo Phamot 43 3E31 . Tu b / Z_ .tf , ). I Cu Ft,
<br /> a 6.2 , PGII ( ) ( ) ( )
<br /> W UN3291 Regulated Medical Waste, n.o.s., ! ; I ; E1D ; al . C onii ated irOK 1 . 32 CURL )
<br /> LouZ 6.2, PGII ( ) r ( ) Cu FL
<br /> a UN3291 Regulated Medical Waste, n.o.s., �}
<br /> 6.21 PGIIKVP 1 a C2 S Cu Ft.
<br /> UN3291 Regulated Medical Waste, mos.,
<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
<br /> Ft,
<br /> 3. Generator's Certification: 41 hereby declare that the contents of this consignment are fully and accurately TOTALS I► j 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 to applicable International and national government dons."
<br /> iVlutls V .� D9le
<br /> 4. TRANSPORTER 1 ADDRESS: Phone #: ( 209) 2 94,,, ? •) 14
<br /> stelicyclej IIID . 1111'et 11S « FIVOW11011 Applicable Permit Numbers:
<br /> 7375 P A tirtdgeford Rd .
<br /> 2 R Sloc 'rfon , CA 95206
<br /> CC TRANSPORTERFICATI(O1N : Receipt of medical waste as describe �(�/J /��
<br /> PrinUType Name r`SJ uQ� C� I1 •i Signature Ly/ �/7 /_ Datey G L LTJ �2alL _
<br /> tooth 5. INTERMEDIATE HANDLER 21TRANSPORTER 2 ADDRESS: Phone 11:
<br /> N
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PdnUrype Name Signature Date
<br /> „ � 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M:
<br /> CC Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: ReBeipt of medical waste as described above,
<br /> Print/Type Name Signature pate
<br /> 7. DISCREPANCY INDICATION
<br /> III I most,"
<br /> 8A. Deaig - M 88, Aioarnate Facility: 8C, AlbmaU Facility: 8D. Albmah Facility:
<br /> 41111110 i ;; F;ricyc'.I �UTnOc iw> ' t+:ri �,cl. , Inc . (InLinerat_:r) "_- teriu; cl? , ins . (Autoclave) C:avanta (,lotion , Irn,
<br /> *5 h rila , Fl 1213 N . Fo : bolo Drilie 277 :9 E . 26th :8t, 4850 BroaWiNe Rood HE
<br /> u' atbbleh 1f1 �-!''(F+" PlC.IIIhSz,!t1.. Va , UT 810134 `ornon , CA 9LI06LI `�rur�lc � 011"" 97 '�fi5
<br /> L
<br /> }] ? )? "4 - 71i4 ("^ 01 )'33 , 1 � 7t (Its I3 '8- 712 '? (r' na )ir18IJ °981� D,.r. . **iAoo 4 L_I .a - :7n PeImit ;t �8 i
<br /> W certify' that I nave 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 /> PdnVType Name Signature Date
<br />
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