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MEDICAL. WASTE TRACKING FORM NUMBER
<br /> 000-0 Stericycle` IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .800-424.9300 STANDARD MANIFEST 001r03-21 -NOCA
<br /> ' ROLfte* 706 " 21 CUSTOMER N0. 21132 MDTKGOI87Q
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> /tTDI Eric CrowleyNJIy 1 � � 1 11111111 ,1311111111 E full
<br /> TfyI�AY DIEric
<br /> V2016
<br /> 312 S FAIRMONT ,'4);%+ E 12/23/2022
<br /> i ODI , CA95240a,*3840 ( 209) 369 - 511, 10
<br /> CUSTOMER NUMBER aJ � - � G£NERATOR's R£wmAOrm N
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. Nos OF 2D VOLUME
<br /> G _ INERS
<br /> 823PGIIRegulated Medical Waste, n.o.s,, IHI3 ( 13io ) Tia ? ( 1"a ) Tr1�i � ( C' 1� ) TXa ( Fll ) 't IIub( a . � � . Cu Ft,
<br /> NONE ROM
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII T H w. ; ( iia )_ --TF 3 .
<br /> Cu Ft.
<br /> tY UN3291 , Regulated Medical Waste, n.o.s., {� R 17iD icXllal'iif Corrugated'� trt3 �ox rk . w
<br /> 0 62, PGII (Bio ) ( ) ga = ( ) Cu Ft,
<br /> QUN3291 Regulated Medical Waste, n,o.s.,
<br /> 621 PGII RX ('�iA QTGasketedSharpCant . ( Ck.l #=t ) Cu Ft.
<br /> Z 6 23 GII Regulated Medical Waste, n.o,s., H (` LAD I asketod c7 erp Cont . CuFi
<br /> ) Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.20 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.21 PGII i 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 /> 6.21 P611 Ft.
<br /> S. Generator's CertlHcatlon: at hereby declare that the contents of this consignment are fully and accurately TOTALS I► Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br /> t L
<br /> are In all respects in proper condition for transport according to applicable international and national governmental regulations'
<br /> Printedfryped Name Signature Date t
<br /> . TRANSPORTER i ADDRESS: Phone N: ( 209 ) 2944111
<br /> stellcycle , tilt: . Tills jus a F 'l'OLfYti Alli lllr�allt Applicable Permit Numbers:
<br /> 71175 R A BfidnefCrt'1 Rd',
<br /> 2 Slocklon ' CA 652 '06
<br /> i TRANSPORTER CERTIFICATION : Recelpt of medical waste as described above.
<br /> PrinVType Name ignature Date 2 r--
<br /> 6. INTERMEDIATE RANDLER / TRANSPORTER 2 ADDRESS: Phone N:
<br /> P1 �` Applicable P rmlt Numbe
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> i
<br /> B. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS, Phone N:
<br /> rr Applicable Permit Numbers:
<br /> ' INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of edleal waste as described above. +
<br /> PfinVrypa Name Signature Date
<br /> I 7, DI SCR ANCY INDICATION
<br /> y sA Designehd Feclllty: 88. Akertute Fecgky: Fj 8C. AlNrnate Facitky: rlD. Atbmate Faculty; y
<br /> F) tericycle , Inc. . (Autoclve) - tericycleA , Ino . (Indnerator) Stericycle , Ino . (A +lteolole ) C: ovanta 1,larion , Ing.
<br /> a "1x 75 P, A E '''' , r da all NO Foxboro Drive 2775 E . 26Lh "t, 4850 Eiroolkialw Road WE
<br /> �l'VED Fkjorki1 Snit Lat2ke , LIT �t1054 Vernon , C11 gqq a3 t� rcolk , OP 67306
<br /> (209 ) 2@44114 8ai ^s -
<br /> 81 '171 ( 866 )'7834422 ; q6 ?33 g3Dq
<br />[ : 14
<br /> RTSA ST . Permt64 m0M ` r
<br /> NT
<br /> FACILITY: I certify that i have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F- received the atjo jodicated wastes In accordance with the requirement outlined In that authorization.
<br /> PrInt/Type Name Signature Date
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<br />�, — - - - - - -- - - - ORIGINAL -
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