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m T MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stencycle° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -800-0249300 STANDARD MANIFEST 00t •03.21 *N00A
<br /> Route tt 706 — 5 CUSTOMER N0. 21132 NIDTKO017EVV
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> AT T N : I~ric Crow ! c}rI � � 1
<br /> TaKAY f7lAI '{ S1S_ DA'diTA #3016
<br /> 3 #12 S FAIRIVIONTAVE 112/ 16/2022
<br /> LOCI , CA95240- 3 40 ( 209) 369- 5418
<br /> CusTomimNu"en 6053303 - 001 GENERATOR18REdsrnAMN0
<br /> MMMMMM
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINERTYPE 2C. . mill F 20. CC/, LU
<br /> 623291iRegulated Medical Wastes n.o,s ,1 PGII1' I- a ( Bio ) T ,43 ( Pa ) T43 ( Ch ) IX4VMMC ± O `
<br /> 3 CT
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o,s., I H 31 B
<br /> 6.2, PGII ( 1o )_ _.TP31 (Pa)__.. TC31 (Ch )___.__ _ TXW1 ( Ph ),_,_ VMVMMVVa1CaITL- :1 ( 4 . 1{ Cu Ft.
<br /> C 623PG11Regulated Medical Waste , n.o.s. , KR ( Bio ) RX ( Pharin ) CCrrugated Pox ( 4 . 3 )
<br /> UN3291 Regulated Medical Waste, n.o.s., Cu Ft.
<br /> CC 6.2, PGII RX GAL/OT c3tnsketed Sharp Cant . ( CuFt ) cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s.,
<br /> W 602, PGII • S3H 0AL IOT �-� asketed P, harp Cont . ( CUFt ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o•s.,
<br /> 6.21 PGI) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII i 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
<br /> Cu
<br /> 3, Gonerstor's C@Aificatlon : "I here declare t 1 the contents o1 this consignment are fully and accurately TOTALS 1110P Cu FL
<br /> described above by the proper shippI name, ajCci are classified, packaged, marked and labelled/placarded, ind
<br /> are In all respects in proper condition or IranspT according to applicable international and national governor Intal regulations"
<br /> Print Name �• SI tura Date
<br /> 4. TRANSPORTER 1 ADDRESS:
<br /> CC ( 209)c ir� t _ Phone N: ( 209) 20=1 -7114
<br /> This s ( 111FOLI � Shipl )VIetii Applicable Permit Numbers:
<br /> 7875 R A i30(1C e d Rdo T`S/0USTIMa0
<br /> `•� tockttlli , CA 952 .
<br /> a ,= TRANSPORT(E'R�CER7IFICATION : Receipt of medical waste as described above, lL
<br /> "Zo 64
<br /> Pr1nVType Name ` _ t 0 " 'Signature Date
<br /> 5. 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 /> Print/Type Name Signature Date
<br /> M 0. INTERMEDIATE HAND 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> INTERMEDI E HANPAMDLER / TRANSPORTER CERTIFICATION : R c pt of edical waste as described above.
<br /> Prrnt/7ype ems Signature Date
<br /> 7. DIS EPANCY IND IQN Lo�
<br /> � t a
<br /> !�
<br /> 0A. Dnlynabd Iltly: 8B✓A `Ihnvte Fecfltty: ttC. ANsm+tr Facility: SD, Animate FecIINy:
<br /> a in cls Inc . (Autoclave) Sterid/cle , Inc . (Incinerator) Stedoyc-le , Inc: . (Aut obie) Covsnta ftiarlon , Inc
<br /> 90 N . Foxboro Drive 42775 Em 20th St , 4850 Brooklake Road N
<br /> t` Stoc {,7 i~l) Norill Salt (Mlike , U T E40154 Vernon , CA 90058 Eraolcs, Grc 97306�
<br /> W ;`.(axil? ) 2 '34 i ,11 �? qq (8 ,31 ) ri35 - 1171 (38Er )7E•3�74AM (= G7 ) "� A3-acI3G
<br /> No
<br /> >1k1'CVic
<br /> �� I+-4481JA- 30' . Permit # 384
<br /> �:.
<br /> TREATMENT FACILITY: I cer`tNy tha i have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> M01610, Noma
<br /> t— recefreceivedthe above Indicated wastes Vol accordance with the requirement outlined in that authorization ,mea
<br /> Signature Date
<br /> rV
<br /> O
<br /> O
<br /> ORIGINAL,
<br />
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