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<,,((rr. MEDICAL WASTE FORM NUMBER
<br /> 400 Sterlacycle� N CASE Q'�NCYNk4ft. CNEMTREC 1 -°OQ•42+"W I�Ju�D1JWA EhT 001 .03.21 •NOCA
<br /> CUSTOMER NO. 21132
<br /> 1 . Generator' N k�1bi*7W4 slephone Number
<br /> TOKAY GIAL.YSISwDAVITA 1721116
<br /> 3 '12 S FAIRIVIONTAVE I I /1t"5/2022
<br /> LODI , CA 95240 - 3840 (209) 3691.,5416
<br /> r iM m
<br /> CUSTOMER NUM*ER GENERATOR'* RsowmTm N
<br /> 2A. DESCRIPTION OF WASTE 2B4 ID ) ` Gil R cinerat8} 4 4 'S a1 , ub ( 2CGN6roF 20. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., CONTAINERS
<br /> 6.2, PGII T62 '! " (Bio) ► P15- (F'�: lh )1 0100111111 _^_ "l Y 'I &-(Cherno ) 20 Gal . Tula ( � .7 Cufl • ) Cu Ft•
<br /> 623PGIIRegulated Medical Waste, n.o.s., T4 t_ ( Io) i'+<4ri- (G' hettia) TI4fl• (lncinerate } 7 6al . EMIR Tu a ( .0 Clift. )111
<br /> Cu Ft.
<br /> cc UN3291 Regulated MedicalWaste, n.0•s., t�VIBASI& io) _Ct file:;" (Cltentct) _ V+/ v�1�- ff'harrn ) �1 ^• GsI . TI� ( 5 .7t= u . S
<br /> 6.21 PGIIy Cu Ft,
<br /> UN3291 Regulated Medical Waste, n.o•s., If __( Pio) C%91 . Corrugated Botc (4 . 3 :: Cult .)
<br /> 6.2, PGII Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s,,
<br /> Z 6.2, PGII
<br /> L1111
<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 /> UN32911 Regulated Medial Waste, n.o.s.,
<br /> 6.21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s,,
<br /> 6.2, PGII Co
<br /> F .
<br /> 3. Generator's Certification: "I hereby declare that the oontente of INS coheignmint are fully and accurately TOTALS ► Cu Ft.
<br /> described above by the proper shipping name, and are classHied, packaged, marked and labelled/piaom., end
<br /> are In all respects In proper condition for transport according to applicable international and national goyemmentei regulations'
<br /> Inc . Z/ 1 (209) 29rwFWXQWjFjM 1 Ld�
<br /> 4. TRANSPd M;
<br /> OCf�1nl3 , ,/� Ji� 6 Appl Permit Numbere:
<br /> TRANSPORTER C FlCATION: of medical waste ae {
<br /> 4%PrinVrype Name �M n Signaturo Date
<br /> S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone e;
<br /> N ,y
<br /> i- Applicable Permit Numbers,
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Recelpt of medleal waste as described above.
<br /> PrinVType Name Signature Date
<br /> i B. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N;
<br /> Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> �• Steri ycle , Inc. (Autoclave ) Sterityole , Inc . (Incinerator) Sta" ric ,cle , Inc. (;autoclave) Covanta Marion , Inc
<br /> dwI_ , u 1 , SE ;` uT 8f1064 i'!� ,. °QI��Fl� I
<br /> IA 1 nL
<br /> U (209)294 A . V6D ( i11 906E 1171 (EBE1)783 422 ( J47 )393 OSLO
<br /> TSfO T8
<br /> r ,0 ,
<br /> . t NOV 1 G 2022
<br /> T EATM� C11 41C at I hale been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> r rdance with "the requirement outlined In that authorization.
<br /> Print/Type Name Signatore Date
<br /> ORIGINAL
<br />
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