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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stencycle• IN CASE OF EMERGENCY CONTACT: CHEMTAEC 1400.42444 STANDARD MANIFEST 001 .021.21 -NOCA
<br /> Route #: 706 -5 CUSTOMER No. 21132 MDTKO012PI3
<br /> 1 . Generator's Name, Address and Telephone Number l ;
<br /> ATI Eric Crowley
<br /> D
<br /> TGKAY iALY S! &DAVIDAViTA #2016
<br /> 312 S FAIRMONT AVE 10/21;/2022
<br /> LODI , GA 95240- 3040 (209) 369 -5418
<br /> 6053303-001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION 0
<br /> 2A, DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. No. OF 2D. VOLUME
<br /> UN3291 , Regulated Medical Waste, n.o.s., 1131 4w(BIo) TP14. (Path) TY14-(Inalnemte) 44 Dal . Tub (. ,@" ,,, HERS
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<br /> 6 232911PGIRegulated Medical Waste, n.o.s., - 101 a 3 ) en70 r . u j d Cult. )
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<br /> CC UN3291 Regulated Medicai Waste, n,o,s„ I 13413W (131p eMo , (1531 n erae ! O a , �J5 ( jq .0 Cuftj
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<br /> UN3291 1I Regulated Medical Waste, mo.s.,
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<br /> UN3229911) Regulated Medical Waste, n.o.s.,
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<br /> UN3291 Regulated Medical Waste, n.o.s.,
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<br /> 9. Generator's Codification : "i hereby declare that the contents of this consignment are fully and accurateLntal
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<br /> described above by the proper shipping name, and are classified, packaged, marked and labell"placardan
<br /> are in all respects in proper condition for transport according to applicable international and national go - ,
<br /> Print Name U SI tttt
<br /> lure
<br /> 4. TRANSP This is a Through Shipment Phone M: -�
<br /> 1875 R A Bridgeford Rd . Applicable Pern I&OFilr80
<br /> Stockton , GA 95206
<br /> CC TRANSPORTER.r�, MFICATION: eceipt of medical waste as described e. 49-0�VE�
<br /> Print/Type NameJLiCJsft ! !� SignatureZ;OOOF h Date Q n
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone C
<br /> NW
<br /> F Applicable Permit Numbers; j
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> PrinOype Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS ; Phone M;
<br /> Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATIQN : Receipt of medical waste as described above.
<br /> Pr(nt(Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
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<br /> n' e or >i. _ _ i ' � . Fo cbaromre S � Bth Vii, , 3ro,offi ,
<br /> lakyc�ad f,lE
<br /> 8'- Plartfi halt Lalte , UT 84054 Vernon , CA 90058 Braoice, OF; 97386
<br /> ual " • (209 vera i (:301 )9:je- 1971 (8Bt3)783-7422 (605)393 0890
<br /> TE4 I 3A-448!JA- 36 Perrnit 0 3154
<br /> OCT
<br /> TREATMENT FACILITY I certify th t I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> FIRM rec�af j�d64( twastes In accordance with the requirement outlined In that authorization .
<br /> ame Signature Date
<br />
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