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. MEDICAL WASTE TRACKING FORM NUMBER
<br /> tf•e,26 Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -00GJ244= STANDARD MANIFEST 001 .03-21 •NOCA
<br /> Route : 703 -6 CUSTOMER NO, 21132 MDTK0013MV
<br /> I . Generator's Name, Address and Telephone Number
<br /> ATTN : Er-icCrowley
<br /> TOKAY DIA YSJSDAVITA #2016 I i I I I I ! 1 t l 11l � 11 1111111 Ix 2224
<br /> 312 S FAIRMCNTAVE 11 /8/2022
<br /> LOCI , CA 05240-8340 (2010) 360-5418
<br /> 605330' - 0D 1
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION N
<br /> 2A. DESCRIPTION OF WASTE 2e, CONTAINER TYPE 2C. NO, OF 20. VOLUME
<br /> 6 23291 Regulated Medical Waste, n.o.s., T61 + (Sia)��TP I �}4Pslh) TY14- (Incinerate) 44 Gal . Tufa ( I , 5L",,TPJNERS
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<br /> UN3291 Regulated Medical Waste, n,o,s.,
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<br /> UN3291 Regulated Medical Waste, mo.s.,
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<br /> UN3291 Regulated Medical Waste, n.o.s.,
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<br /> 3. Generator's Certlficetion : "I hereby declare that the contents of this consignment are fully and accurately TOTALS 1101 �7 , . 3 Cu FL
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placardad, and
<br /> are in all respects in proper condition for transport according to ap
<br /> plicable International and national governmental regulations"
<br /> Pd Name �' t sl re Z Z'
<br /> 4. TRANSP RF Thie is a Tivough Shipment Phone N:
<br /> t 8715% R A 1=1ridLgeford Rd . Applicable Parr i"I r'ut)
<br /> Sbckton , CA 05206
<br /> TRANSPORTER
<br /> FICATIO ipt of medical waste as desc ' veP.
<br /> Print/Type Name I ►'L 1 n rL signature /� Y"!` f Date
<br /> 5, INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> a Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> Appllcable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION :' Receipt of medical waste as described above.
<br /> Pdnt/Type Name Signature pate
<br /> 7. DISCREPANCY INDICATION
<br /> ec l C, emit ani 1
<br /> 7876 1�,YRd , go ftl , Faxbara rive 2776 E , 26th St , 850 Brooklake Road NE
<br /> MOWNJ atockt�k+( . {7 North Salt Lake , UT 84 054 Vernon , CA 90058 , 13roalcs, CJf� 97305 �
<br /> LL `- t2p9)2g4--71(1� 4qq (n� (801 ) 936- 1171 ($56)783. 7422 (6135)383-G320
<br /> I.. . . scf�i�V� �+ V LLr�� o .i ,tno��t, �• a n „� .vp �N 'DRA
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<br /> REd'111 W I F41CTf)r ify the I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> N receive a taDove Inalu accordance with the requirement outlined In that authorization ,
<br /> Print/ ype Name Signature Date
<br />
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