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�f- � 7ttt� MEDICAL
<br /> -yyWASTE 44TRACKING FORM NUMBER
<br /> Steri�y� le' IN CASE �MENCMISOHT�; CNEMTREC 1400.4241 M lyi7rl�� O11130EIST 001 .03.21 •NOCA i
<br /> CUSTOMER NO, 21132
<br /> 1 . Generator' a ' *Telephone Number
<br /> TOKAY DIAMIS-DAVITA #2016 11111111 Ell 111111111011 '17 11
<br /> 312 S IwAiRMONTAVE 91 /4/2022
<br /> LORI , CA 952411-3840 ( 209) 369-5418
<br /> 0 3 Q3,,%QQ1
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION N
<br /> 2A, DESCRIPTION OF WASTE 2B. - IQ -( 8 ,GONTA meta � a , r! OF 2U. VOLUME
<br /> UN3291 Regulated Medical Waste, n,o.s., CONTAINERS
<br /> 6.2, PGII T621 - (Pio) TP15- (Fath ) T ! 16-(Chema) 20 Baal . Tub ( 2 7 Cuft. ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.os., TB40_ Bio {Y4p- ChetYio Tl4gt Inoinerate 37 C; al . Tu
<br /> 6.2, PGII ( ) ( ( ) (4 .9 Cuff. ) Cu Ft,
<br /> M UN3291 Regulated Medical Waste, n.o.s., VV843-( ao) GtN43- (Chemo) WX43- (Pharm ) 3 Coal . Tu ( 6 .7Cu
<br /> 0 6.2, PGII � 6760 Cu Ft.
<br /> Q UN3291 Regulated Medical Waste, n.o.s., hP ( Bio) ,__.__�Gal . Corrugated Box (4 . 32 Cuft .)
<br /> W 6,21 PGII Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s.,
<br /> iZ 6.21 pGll 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, PGII Cu Fl.
<br /> UN3291 Regulated Medical Waste, n.0,9.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o,s.,
<br /> 6.2, PGII F Cu
<br /> Ff.
<br /> 3. Gtnsrstor's Certification; 11 hereby declare that the contents of this consignment are fully and accurately TOTALS O • Cu Ft3
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelleWplacarded, and
<br /> are In ail respects In proper condition for trans rt according to applicable International and national gove tions"
<br /> (205) 2547 ' 4
<br /> Print "InAe ro
<br /> cc 4. TRANSP R Phone N: ��
<br /> 0t�vckfan , A 95206
<br /> Applicable Permit Numbers;
<br /> � a Irn
<br /> d TRANSPORTER FICA Recelpt of medical waste as descri bove,
<br /> PdnUType Nemer�`��t1 C l Jt Signature /n DateSo INTERMEDIATE INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; Phone N:
<br /> N Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinU1'ype Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 31TRANSPORTER 3 ADDRESS, Phone N:
<br /> Applicable Permit Numbers:
<br /> ' INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Pn'nVType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> do toclave Stetioycle , Inc . (incinerator) Stericycle , Ina. (Autoclave ) Covanta Madon , Ino
<br /> uL (a VED � 1 ✓1IiT!UT84064 h' i , r �d 05A1 vh"g'Iv 4 v
<br /> 20MI9 4114 (8 ) g30- '1 .171 (&06)71;3-7422 ( 605)39 -08g0
<br /> 3A 4481JA oG Fi rl'r�t # 36q
<br /> ul did;11'
<br /> w TREATMENT FACILI : been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the above indicated wastes In accordance with the requirement outlined in that authorization .
<br /> Print/Type Name Signature Date
<br />
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