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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stericyclee IN CASE OF EMERGENCY CONTACT: CHEMTREC 1800.4249300 STANDARD MANIFEST001w03.21 •NOCA
<br /> ROUte #: 703+ 9 CUSTOMER NO. 21132 MEITK001GZA
<br /> 1 . Generator's Name, Address and Telephone Number ( l 1
<br /> Eric
<br /> TOKAY DIA YSi �tDA�ITA �#2t19G
<br /> 01
<br /> 12 S FAIRt�1ONTAVE 12/13/2022
<br /> LOU ) CA95240-3840 ( 209) 369- 418
<br /> CUSTOMER NUMBER 6D5330M01 GmtRATows REOISTRATM 0
<br /> 2A. DESCRIPTION OF WASTE 2B, CONTAINER TYPE 20. NO* OF 20, VOLUME
<br /> UN3291 Regulated Medical Waste, n•o•s•, CONTAINERS
<br /> 6,21 PGII 9 T E14 -(Bia ) TP14 - ( Fath ) TY '14 - ( Incinerate ).• 44 Gal , Tu 7 ( 5 . Kuft) Cu Ft.
<br /> UN3291
<br /> 23Regulated Medical Waste, n,o.s., 7 Lt , )29I T !321 - (Bio ).
<br /> Cu Ft.
<br /> IZ UN3291 Regulated Medical Waste, n.o.s„
<br /> 6.2, PGII TF340J lBio ) YJB ( _ herno T141 ( Incnerate ) 37 Gal . 'Li7 4 . = C .
<br /> )O Cu Ft,
<br /> IM
<br /> UN3291 Regulated
<br /> Regulated Medical Waste, n,o,s„ ',�/L'G 3 ( i� ip )�' �t1�13-(Ghel'na ) WX4 ( Phami )•_,__ 43 Gal . LIt7 ( 5 . r , uft ) I - Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n•o.s„
<br /> 6.2, PGII ltiR (Pia ) Coal . Corrugated Pox (4 . 32 Gout, ) Cu Ft.
<br /> W
<br /> 642, 291 Regulated Medical Waste, n.o.s., 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 /> 6.21 PGII Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o,s.,
<br /> 62, PGII Cu Ft.
<br /> 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► r ' Cu Ft,
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br /> are In all respects in proper condition for transport according to applicable International and national governmental regulations *•
<br /> Print Name ture Date
<br /> 44 TRANSPORTER 1 ADDREESSSSA Phone N: ( 209) 2911-7114
<br /> a 4 tericyele , 111C . This is a ThroL10h Shipment Applicable Permit Numbers:
<br /> 7575 R A Bridgeford Rd TSiOST 80
<br /> S Sloe ton , CA 95205
<br /> RE TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, l/
<br /> PdnVrype Namop ) med 2ge Signature Dale 1 Z ( 3
<br /> 6a INTERMEDIATE HANDLER 2 / TRANSPOFITER 2 ADDRESS: Phone If:
<br /> `V Applicable Permit Numbers:
<br /> i
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PdnVfype Name Signature Date
<br /> I
<br /> r, 8, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone 8:
<br /> cc I
<br />� Applicable Permit Numbers:
<br /> lul
<br /> INTERMEDIATE ANDLER ! TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> r Printrfypo a Signature Date
<br /> 7. REPANCY INDICATION
<br /> SA. Deslgnated Feciihy: 88. Albmete FadlNy: SC, Akemete FecNfty: ED. Aftemete Kecllity4
<br /> Fc
<br /> z ; Ry NLEr SI+ ) tericycle , Inc . (incinerator) Stericycde , fnc . (Autoolave) Cownta f9 rlon , Inc
<br /> 5 RA r' { 0 N . Foxboro Onkle •7. 775 F , 26th St, 4850 Rraaklake Load PIF
<br /> �r. Ron , C No' au i OrthSaltL. alte , lJT8114054 Vern�7n , C:A P0058 Brooks, Cir fl7305
<br /> 6i iL 366 78 '34422( ) (5'OT A;44b1 W36 Pern* 364
<br /> TEATM T FACILITY: I c ��ify that I h e been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> t- r eived ttWi'tiliwredWe� in ac ordance with the requirement outlined In that authorization,
<br /> Print/Type Name Signature Date
<br /> ORIGINAL.
<br />
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