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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stericycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -800-0249300 STANDARD MANIFEST 001 •03.21 •NOCA
<br /> flouts; #. 703 - 10 CUSTOMER N0. 21132 MDTt OD17P2
<br /> I . Generator's Name, Address and Telephone Number
<br /> ATT J : Elpic Croviley
<br /> TQKAII' DIALYSIS- DP 4TA 6#2016
<br /> 312 S FAIRIVIONTAVE 12/20/2022
<br /> LODI , CA 952110w3841) ( 205) 36M ,1 •10
<br /> CUSTOMER NUMBER 6053 1 00110M01 GENERATOR's REGISTRATION N
<br /> 2A. DESCRIPTION OF WASTE 284 CONTAINER TYPE 2C. Nor OF 20, VOLUME
<br /> 623PGIfRegulated Medical Waste, n.o.s., TN43 ( 9io ) TFd3( F'a ) TC 17 ( Ch ) ___Tr; # � (f ' l1) a3 � ER
<br /> : al , uls(
<br /> ys curt,
<br /> UN32291Regulated Medical Waste, n,o.s.,
<br /> 6PGII T Nib j C10 n ` ?
<br /> { )_. _ TPLj (Fa )_ TC31 (Cf, ) _ T � j {Pfii _ _ , j 1aITI., 3( Q . 1 Cu Ft.
<br /> CC UN3291 0 62, PGII Regulated Medical Waste, n.o.s., Fri ' BID RX PI�arn� Corr.t ated Boy; (RA . 3 '
<br /> ( BID ) ( ) �i ' (' 1 Cu Ft.
<br /> Q 623291 PII Regulated Medical Waste, n.o.s., R X. 0AL/CDT Ca =keied Sharp Cont , ( C:• uFt ) Cu Ft.
<br /> W623 PGII Regulated Medical Waste, n,o.s., 13 11 GAL/CiT13asketedSharpCont . { C>_IFt ) Cu Ft.
<br /> UN329t , 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 /> 621 PGII 4 Cu Ft.
<br /> UN329t Regulated Medical Waste, n,o.s.,
<br /> 6.20 PGII u Ft.
<br /> 3. Generator's Certification: 41 hereby declare that the contents of this consignment are fully and accu ely TOTALS ► Cu Ft.
<br /> described above by the proper shlppin name, and s classified, packaged, marked and labelled/placar , a
<br /> are In all respects In proper condition transpo ccordIng to applicable International and national gov me tal regulations * /
<br /> Pri Name naturo Z •� " '�` �/ Date
<br /> "U � �
<br /> 4. TRANSPORTER 1 ADDRESS: Phone N: ( 209 ) 2911 .7114
<br /> '194
<br /> stericycl ;' , Trig . This is it `I Ilrot jt ] shipment Applicable Permit Numbers:
<br /> 7 +75 R A L�riticftifo RcI T' 1L jL� 7t �; U
<br /> a Slot; loll # CA 9520
<br /> a TRANSPORT ERTIFICAl10 eFelpt of medical waste as above.
<br /> PrintRype NameVilV\VQ
<br /> Sig
<br /> Date v ' y
<br /> N b, INTERMEDIATE HANDLER 2 / TRA SPORTER 2 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 /> 6. 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 /> PrinUType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> Dsstynatsd Facility* $8, Attems% Faellity: SC, AHamata Faclltty: LD. Alternate Faclilly:
<br /> ttrioyolc; f~tYA,�qr;_1 .tericycde , Inc. (incinerator) tericycle , Ino . {Auto� clavE ) Covanta Harlon , Inc
<br /> a 7075 RA j dEO ' u N . Foxboro Cl &e 2775 E . 26th 5t, 4 $ 50 Prookiake Road NE
<br /> t'- `te� lton ,
<br /> CA g5v}2Uc qqqq Jordi SaftLake , UT C-4054 Vernon , CA (913058 gooks, 010, 117305
<br /> I W (2 Q` ?04gg lei G Z , ZOZZ B01 ) 0304171 (8136 )7834422 (505 ) 303- 0800
<br /> dd T t9s Q , T a_.Ia A-448/IX36 Permit # 364
<br /> W PEA T FACIS�,y�: _II hat I hive been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> r eived
<br /> Trelet s In allcordance with the requirement outlined In that authorization.
<br /> LN PdnViype Name Signature Date
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<br /> ORIGINAL.
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