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T MEDICAL WASTE TRACKING FORM NUMBER
<br /> 4*0 Stericycte IN CASE OF EMERGENCY CONTACT: CHEMTREC 1400=4244300 STANDARD MANIFEST 0011 •03.21 .NOOA
<br /> Route #. 706 - 9 CUSTOMER NO. 21132 MDTKO01206
<br /> I . Generator's Name, Address and Telephone Number ff ff ii f
<br /> ATTN : Eric Crowley
<br /> TOKAY GlALYSI S- GAVITA #2016
<br /> 312 S FAIRMONTAVE 10/21 /2022
<br /> LOCI , CA 95240-3340 , ( 209) 369-641 S
<br /> CUSTOMER NUMBER 6053303- 001 GENERATOR'S REGISTRATION ff
<br /> 2A. DESCRIPTION OF WASTE 26. CONTAINER TYPE 2C. Noe OF 20. VOLUME
<br /> UN3291 Regulated Medical Waste, n,o,s., CONTAINERS
<br /> 6.2, PGII TB14 -(Blo ) TP '14 - ( Path) TY14 - ( Inclnerate ) 44 Gal . Tub ( O . OGuft) Cu Ft.
<br /> 623PGjIRegulated Medical Waste, n ,o.s„ TB21 -(8io ) TP15-(Path )_,_, TY16-( Cherrjo ) 20 Gal , Tu (2 . 7CUft . ) Cu Ft.
<br /> MM
<br /> CC UN3291 Regulated Medical Waste, n,o.s„ ^ 7 Gal .
<br /> 6.20 PGII T849-( Sia ) TY49-(Chemo) T1413 Incinerate ). 87 � tb (4 . 9Cu . ) Cu Ft.
<br /> 6,20 PGII Regulated Medical Waste, n.o.s., W34 3 BIo 0W4 8- (Che rno . V\1X4 3- Pham 43 Gal , Tub 5 . 7
<br /> W UN3291 Regulated Medical Waste, ri ,o.s„
<br /> tZ 6.2, PGII KR ( Elio ) Gal . C'ontlgated Brix (4 . 32 CUft. ) Cu Ft.
<br /> 23291, „
<br /> Regulated Medical Waste, n ,o,s
<br /> 6
<br /> Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n,o.s„
<br /> 6.21 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, PGI, Cu
<br /> Ft.
<br /> 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS lot 3 1e Cu FI.
<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 transpo ccording to applicable International and national government w{slisna:c—, _ L
<br /> 1 NambAt!� montun DOo
<br /> 4. TRANSPORTER 1 ADDRESS: Phone N : ( 209) 294-717
<br /> Stericycle , Inev This is a Through Shipment Applicable Permit Numbers:
<br /> Milt 7875 R A Sn'dgeford Rd . TS/OST 80
<br /> a Stockton , CA 95206
<br /> CC
<br /> p�C TRANSPORTERCrJMFICATI0 : eceipt of medical waste as descr
<br /> ~ PrinVType Nam, . / V �' f Signature C G l�7 �YL Date C�'L• 1 / 2�,G�
<br /> .` 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone A.
<br /> N Applicable Permit Numbera:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PdnVType Name Signature Date
<br /> i B. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION :' Recetpt bf medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> tfa, Attsmab Facility: SC, Akamab FadlNy: nD. AltornaM Facllity:
<br /> Sterioycle , nc e) terlrycle , Inc . (Incinerator) Stericyole� , Inc . (Autoclave) C:ovanta 1pl,larlon , Inc
<br /> d
<br /> 78-76RA r M'1�13a 0 N . Foxboro Drive 2775 Es 26th St, 4860 Srcaklake Road NE
<br /> u' St4',*on ( .0 lorth Salt lake , UT 84054 Vernon , CA 90058 Brooks, OR 97305
<br /> (2U.k'94 Z�ZZ 841 )936- 4175 (888 )783- 7422 (505 ) 393- 0880
<br /> TWOSWO A-448rJA-se PerrHt # 464
<br /> T EATMeel at I h e been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> It s in a ordance with the requirement outlined in that authorization .
<br /> PrInUType Name Signature Date
<br />
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