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• ____ _ - - — — MEDICAL. WASTE TRACKING FORM NUMBER <br /> Stericycle' IN CASE OF EMERGENCY CONTACT: CHEWMEC 1 -tll1 "24- M STANDARD MANIFEST 001w0•2t -NOCA <br /> Route #. 703 _5 CUSTOMER N0. 21132 MDTK001 <br /> I . Generator's Name, Address and Telephone Number <br /> I D <br /> ATErle CrowleyIII II IIIIIII�IIIIIII111111 II II IIII111III <br /> ' TC►KA5' L7ALY SlS- DAVIVITA #201S <br /> 312 S EAIRMONTAVE 1111 /2022 <br /> LODI , CA 55240-3340 (209) 369- 5418 <br /> CUSTOMER NUMBER G053.�03. 001 GENERATOR'S REGISTRATION <br /> 2A, DESCRIPTION OF WASTE 284 CONTAINER TYPE 20, Not OF 2D. VOLUME <br /> UN3291 Regulated Medical Waste, n•o.s., CONTAINERS <br /> 6.2, PGII TB14-(Bio) TP1 1 (Path) TY14- (Incineraat .. ) 44 Gal . Tub (• . 00uft) Cu Ft. <br /> 8232911 Regulated Medical Waste, n.o.s,, TEt21 _ (f310) TP15- (Path ) TY 15-(C:herno) 20 Gal . Tub ( 2 7 Cult. ) Cu Ft. <br /> OUN3291 Regulated Medical Waste, n.o.s., T649_(Bio) TY49_(Clterno) TI49- (Incinerate) 37 Gal . Tu ) ( 4 .0 Cuft. ) <br /> 6.2, PGII Cu Ft. <br /> 6232911 Regulated Medical Waste, n.o.s„ `�/g43.(Ega) M%143- (Cherno),�,�, WX43- (Pharm ) 43 Gal . TuCC i ( 5 .7Cu % 9 Cu Ft. <br /> W UN3291 Regulated Medical Waste, n.o.s., K13 �( Bi0) Gal . Corrugated Box (4 . 32 C uft .) <br /> W 6.2, PGIi — Cu Ft. <br /> 6UN32291 Regulated Medical Waste, n.o.s., ' '� (; ! Cu Ft. <br /> Ectil, PGII <br /> �IVV C • <br /> 6UN3229G1i1 Regulated Medical Waste, n.o.s„ /1 �j <br /> Cu Ff. <br /> UN3291 , Regulated Medical Waste, n.o.s., n Q 1 ' <br /> 6.2, PGII G t Cu FL <br /> UN3291 Regulated Medical Waste , n,o.s„ <br /> 6.2, PGII 4 CU Ft. <br /> 3. Generator's CerlIftation: 1 hereby declare that the contents of this consignment are fully and accurately TOTALS 00� . Cu Ft. <br /> described above by the proper shipping name, and are classitfed, packaged, marked and labelled/placarded, and <br /> are In all respects In proper condition for transport according to applicable international and national governmental re ul ae?x-^� <br /> Print Name 31 tura a Zq' <br /> a 4. TRANSP0ff6f1d R+t This i8 a Through shipment Phone R: <br /> 7875 R A Hnidgeford Rot , Applicable Pernll►�r,TM.. T.P. so <br /> Stockton , CA 95206 <br /> ME <br /> t Z TRANsPoFrrEFICATi Receipt of medical waste as describtdalimive. <br /> ~ POnVrype Name Bre Cd 1 Signature ( !A /Z QS7 ♦ Date f [ l( J <br /> S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone C <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> ti. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N: <br /> Applicable Permit Numbers: <br /> W <br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above, <br /> Print/Type Name Signature Date <br /> 7. DISCREPANCY INDICATION <br /> I I nk^ a 240go* Wtgncinerator) [34Qr'A"*0a6*)too1Bve) qWA fP1C►Wr <br /> . , (Pflnt/Type <br /> 75 Fwu , <br /> 90 N . Foxboro Drive 2776 E . 28th St, 350 Brooklake Road NE <br /> stoc'rktANorth Salt Lal?e , UT 84054 Vernon , CA 90050 Brooks, OR 97305 <br /> to <br /> lea (209)2847194 (20i )C1313- 1471 (866)783-7422 ( � - <br /> D b 02 2022 = 3A-440/JA- 36 Permit43 _ <br /> NOV 0 4 202AIEAIT�F t1:Yfy that have been authorized by the applicable state agency to accept untreated medical wastesand that I have <br /> iV e a iPS`�aaastes i accordance with the requirement outlined in that authorization. ,grip Name Signature Date i "'0 ' It'�` " i <br />