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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 1N CASE OF EMERGENCY CONTACT: CHEMTREC 1 ;,aoG*4249300 STANDARD MANIFEST 001 -03.21 •NOCA
<br /> Stericyclem
<br /> ROL11e 4fa. 708 - 11 CUSTOMER N0. 21132 1+1 D K001GPU
<br /> I . Generator's Name, Address and Telephone Number
<br /> ATTN : Eric Crowley
<br /> TOKAY DIAL YSi a,, D 'tV I fA 2016 111 If Ili l ll i II i 11I1 I �fl l { i l l
<br /> 312 S FAIRIVIOVTAVE '12&2022
<br /> LODI , CA95240 -3 40 ( 209) Z69-5410
<br /> CU8TX053303- c� 01OMER NUMBED GENERATOR'S Reo1sTPATI0N M
<br /> 2Aa DESCRIPTION OF WASTE 29. CONTAINER TYPE 20. NO., OF 20. VOLUME
<br /> 623 PGIIRepulatedMedicalWaste, n.o.s., Tg •l ;l _ ( Bio )_.TP14- ( Path ) TY94 - ( Irlc:lnsrate ) 44 Gal . Tu (o JC" f)
<br /> Cu Ft.
<br /> 620PalI3291 RepulatedMedicaiWasle, n.o,s., TB21 -(£bio ).,TP1 �- (Path )_ TY •15-( G'11ert1o ) 20 la al . Tub (2 .7 Cult . )
<br /> Cu Ft.
<br /> CC
<br /> 623 PGII 91 Regulated Medical Waste, D40496, TCa9413ioI _TY49 - (Chemo ) 114LD ( InCiner, e ) a ( C . )
<br /> t 7 Gal , L117 4 . i Cis Cu Fl.
<br /> 623 PGII RegulatedMedlcalWasle, n.o.s„ IYA/9L 3.0310 )_ „_ CV-043-(C1 erno ) WX43-( Phanaan ) 43 GaL Lib ( 5 . 7 ) �
<br /> Cu FL
<br /> W UN3291 Regulated Medical Waste, n.o,s„
<br /> tZ 6.21 PGII i% R_,__.__.(13Io ) Gal . Con-LiUated Eox ( 4 . 32 Cult. ) Cu Ft.
<br /> �r 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 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 /> 6.24 PGII I Cu Ft,
<br /> 3. Generetoes Certs lMlon: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► 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 Iranspording to applicable International and national governmen I re tions" .� /1
<br /> wapp�
<br /> Pdnt Neuse SOO
<br /> tura Date J !i(/
<br /> 4. TRANSPORTER 1 ADDRESS: �: ( 209) 294 "7111
<br /> S ►cricycle , Ine . This IS rc1 Thl'01.1911 Shipment pp bie Permit Numbers:
<br /> 7875 R A Bridgenford Rd . TS/0S"F 1310
<br /> Stociton , CA 95200
<br /> TRANSPORTERFICATiON : j1poer of medical waste as described
<br /> PdnVType Name kVel t! Slgnature GX� /? �� 1� --- Date
<br /> `a 6. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; Phone 8;
<br /> Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/type Name Signature Date
<br /> i 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N: 1
<br /> 15 Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of edical waste as described above.
<br /> PrinMpe Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> _--RYAWELISE_
<br /> kernate FaeflRy: aC. Akemate Facility: dD. Altamab FacNtty:
<br /> v C ericyole , Inc. VED
<br /> , � t icycle , Ino . (incinerator) Mteric�ycle , Inc . (Autoclave) C:ovanta Marion , Inc
<br /> .t 7 175 F?'r� tori . o a uG J . Foxboro Drive. 2775 E . 26th St , �{ S5t3 Flrooltlal?e Pond I'! E
<br /> u" w ,�r1;r;,�! C:f: Cri ,13 , : . _PJa 1; ' alt Lala , UT [3131]54 Vernon , CA 9005D gaol? . CF 97305
<br /> i13 ) 'l91#? 710 Q22 i 8t7 �rAj 1 .179 St3F 78S -7A ? 2 ( 5i� ; ^ g3 - QS9Q
<br /> T ,/OST'�3a 3A '98/,!A-Ad Permit # 361
<br /> TRE TMEN have een authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> H recei ance with the requirement outlined in that authorization.
<br /> Pr(nVType Name Signature Date
<br /> N
<br /> O
<br /> ORIGINAL
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