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• MEDICAL WASTE TRACKING FORM NUMOER
<br /> 0D Stericycle IN CASE OF EMERGENCY CONTACT: CHEMTfREC 1400424A3W STANDARD MANIFEST 001 .03.21 -NOCA
<br /> CUSTOMER NO, 21132 i
<br /> 1 . Generator's Name, Address and telephone Iirt�ir Mr#, 70U 4 MM00315BO
<br /> TQK,'1Y DIfiLY :=:I ! %- D/lVITAp 'ir
<br /> 3 .12 S FAIRIv ONT A11C '1111.2512022
<br /> LODI , CA 95240- 40 0 (209) 3139- 54 `€ 8
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION N
<br /> 2A. DESCRIPTION OF WA CONTAINER TYPE 2C, Nos OF 20. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., CONTAINERS
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<br /> UN3291 Regulated Medical Waste, n.o.s., ' 4 iA) TP '1ti -(€✓2111) %Moat- (Int,IneCaPe ) 44 �I . Tut + ( . tlCuii)
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<br /> UN3291 Regulated Medical Waste, n.o.s„ '� " - ( 1 ^) I r' "- ( dtil i' 15 ( C I'r8rr14) .! C9al . U :_ 77 UI � •
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<br /> W UN3231 Regulated Medical Waste, n.o.s., V `h - � oJ_. � r ` � ( letilo ) _ - rrartll � �t � C, 5 . I U
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<br /> UN3291 Regulated Medical Waste, n.o.s.,
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<br /> UN3291 Regulated Medical Waste, n.os.,
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<br /> UN3291 Regulated Medical Waste, mo•s.,
<br /> 6.21 PGII QU F
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<br /> 3. Generator's Cedt icatlom "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► � ! a , Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, end
<br /> are in all respects in proper condition for transport according to applicable international and national governmental regulaif �f
<br /> PrinteMYpeodName CI-1 r�/S nature Data ds
<br /> 4. TRANSPORTER 1 ADDRESS: Phone N: � [� ry� ���� 7 �
<br /> `� 1 r'ieycle , € IIC . Applicable'i'df15111 �G1TibeiV4
<br /> t R Dr'i4ic 1 fnrrl Incl . ❑ This is 0 `fhrol.10 Shipment
<br /> g 7'11.7713 � s
<br /> TRANSPORTS t ' 1h,F11 : Receipt of medical waste as descri
<br /> PrintiType Name Q �- 14 Signature Date
<br /> 5, INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone M
<br /> N � Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print(Type Name Signature Dale
<br /> M 6, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone M;
<br /> Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PdnUType Name Signature P Date
<br /> 7. DISCREPANCY INDICATION
<br /> lSsafpnNsd F Ba. knKnoft Facility: Q NC. Attamats FaclUty: 80, ANsrns% Facility:
<br /> ib3rtCrGl@ , Ir Sat • ic.yQle , Inc:. Qneinerator) Steric•;'cle , Inc. (Autoolsve ) Csvanta Marion , Inc
<br /> a 876tR A Pridgeford Rd , 90 11 . Foxboro Dnve 27 '15 )= . 26tIT St, 4850 Ctroolclalte Road NE
<br /> 3tot 1610) , 12FT 20224 No th Salt L:*e" , UT 84 054 Vernon , CA 00062 Broolta, OR 07305
<br /> rz 200Tt :I t i' F�1 ' (8( I )J"ig 1171 1 1 4 (380)732-74Uj 22 (5Q5)39a^ p490
<br /> aQt > C�STSU :;A 44WA- 18 Permit # 334
<br /> TR been authorized by the applicable state agency to accept untreated medical wastes and that I have II
<br /> F- received the above Indicated wastes in accordance with the requirement outlined In that authorization .
<br /> Printlrype Name _ Signature Date
<br /> ' I
<br /> ORIGINAL
<br /> I
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