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MEDICAL WASTE TRACKING FORM NUMBER
<br /> �i-6 Stericyde• IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-a00-424*9300 STANDARD MANIFEST 001 .03.21 •N0CA
<br /> ROtIte A 70"• -. 5 CUSTOMER N0. 21132 MGTK00 'IGCD
<br /> 1 . Generator's Name, Address and Telephone Number ll {{
<br /> , TTN : Eric GrQ1 :' Icy � 1 � I
<br /> -t' OKA,Y D1ALYS1S%-pAc/! Tri #2016
<br /> 312 S FAIRMONTAVE 12/27/2027
<br /> LOU , CA95240- 3U40 ( 209 ) 36M418
<br /> CUSTOMER NUMBER GENERATOR'e REGISTRATION N
<br /> 2A. DESCRIPTION OF WASTE 2890 CONTAINER TYPE 2C. NO. OF 2D. VOLUME
<br /> CONTAINS
<br /> Ad UN3291 2911 Regulated Medical Waste, n.o.s., TI ;;12. ( Wio ) � TP43 ( Pa ) TCC ( Gh ) TX4 '� ( Ph ) dKea Tia ' . , , 0 - Cu Ft.
<br /> 623 PGII 91 Regulated Medical Waste, n.o.s., TH-131 ( Bio )_ TP41 ( Pa )_ T03 '1 (Gh ) T )�31 (,GiI )_ 3IG=MTr- )( 441 / Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.s., KR ( Bio ) P ; ( Fh :�tin ) Corrugated Go , (43 )ps,2, PGll Cu Ft.
<br /> E" UN3291 Regulated Medical Waste, n,o.s,, , ,
<br /> Q
<br /> 6.2, PGI i H i 2 ,; dl 13T Ga = :; =ted 'sharp C: unt . ( � . C' !1R � • Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s., r; i r a - Cu
<br /> Ft )6.2, PGii SiH f A_ CIT ,3asket _ d ...,hmp Cont . ( IFt ) Cu Ft.
<br /> 6 23291 , 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 /> 6.2, PGil Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s. ,
<br /> 6.2, PGiI Fl.
<br /> 3. Generator's Certification ; "I hereby declare that the contents of this consignment are fully and accurately TOTALS 7. & Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelied/placarded, and
<br /> are in aii respects in proper con'ditition for
<br /> transport acco to applicable International and nallonal governmental agate s
<br /> 1�/' � ��✓
<br /> Print Nsrrle ti DO* lux
<br /> 4. TRANSPORTER I ADDRESS: PhNT N: ( 209 ) 29 . .4 .1
<br /> Slaticyclfa ? Inc . � `, This is a Through Shipment able Permit Numbers:
<br /> a 7 :;75 R A Bridgeford RSI .
<br /> $ `loc loo , CA 95206 ;
<br /> Z TRANSPORTS FICATIONe R�eeoe t of medical waste as desk '
<br /> Print/Type Name �%�'CL.. QS 104 Signature 4;� l•4a �"� `�•r� Date
<br /> b. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> a Appiloable Permit Numbere:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PdnVType Name Signature Date
<br /> i
<br /> S. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br />[ Applicable Permh Numbers:
<br /> i
<br /> a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> r Print/Type Name Signature Date
<br /> i
<br /> 7. DISCREPANCY INDICATION
<br /> i
<br />[ y Deslgnatsd Facility: 813, AItomats Facility: SC, Athmate Fadlky:
<br /> .J ~ ra� ICy�O$E'.4ILVAtccla�!? ) r: terfCl�cl � , Inc . (Indrierator) Stericycle , Inc . (Autclsleve) : , Cav ,�U� yE nc•
<br /> i
<br /> Q 01876# , �P1 Rd . 00 fill Fo ;ct+oro �trivP 2775 E . 26th Sr. 4P � lArraoikiali6 HKred 1k1E
<br /> Al
<br /> F � '; tockton , CA 06205 Nortft Balt Lake , UT 840541 Vernon , C:A X10058 � F��>�s �
<br /> l' W c209DEE7118 202'd ( > , f )�:a 1171 (<< e i ) 7a3 -7�1zz (505 ) x93 -
<br /> 2 �' ,�TClou °0 ? A5 4 8kIA-3o Ir
<br /> - ..64 `j
<br /> ATMENTFA WITY: I certi hat I have been authorized by the applicable state agency to accept untreat S ta+ I have
<br /> F ed the above Indicated wastes in accordance with the requirement outlined in that authorization ,
<br /> Print/Type Name Signature Date
<br /> li
<br /> 1(
<br /> ORIGINAL
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