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MEDICAL WASTETRACKING FORM NUMBER
<br /> �6 Stericycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .800-4249300 STANDARD MANIFEST 001 03.21 -NocA
<br /> Route # 703 - 11 CUSTOMER NO, 21132 MDTKO01 DAC
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATEtta; Crowley
<br /> TQKAY >aA!_YSI S-DAVlTA #2016
<br /> 312 S FAIRMONTAVE 2 /14/2023
<br /> LODI , CA95240-3840 ( 209) 369-5418
<br /> 6053303- 009
<br /> CueTOMER NUMaEA GENERATOR'S REQIaYRATTOtI t
<br /> 2A, DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C, NO, OF 20, VOLUME
<br /> 623PGIl Regulated Medical Waste, n.o,s., 14 ( Pio )_ TP43 ( Pa ) TC:a ?( Gh ) TX43( Ph ) � c� � ( © „ 9SCu Ff.
<br /> 6232P9G1i1Regulated Medical Waste, n.o,s„ TH31 ( Pio )__ __ TP31 (Pa ) TC31 (Ch ) TX31 (Ph ) 510alTL b(4 . le
<br /> Cu Ft.
<br /> C 62, PGII Regulated Medical Waste, n,o,s„ leR F CD RX ( Pharrn ) CormOated Box (4 , 3 ) J40 3 Cu Ft.
<br /> f UN3291 Regulated Medical Waste, n.o,s.,
<br /> CC 6.2, PGI) R X GAI OT Gasketed Sharp Cont . ( CuFt ) Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s„
<br /> W6.2. PGIi • SH GA.UOT Gasketed Shaip Cunt . ( CuFt ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,0A,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Wakte, n.o,s, , Cu Ft.
<br /> 6.2, PGI )
<br /> UN3291 Regulated Medidal Waste, n,o.s. ,
<br /> 6.2, PGO Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.2, PGIi [` Cu Ft
<br /> 3. Gswotoee Ceftaficatlow "I hereby declare that the contents of this consignment are fully and accurately TOTALS Pop J 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 transport according to applicable international and national governmental regulations"
<br /> PrInteWfted Narm Signature qL4 Bata
<br /> 4, TRANSPORTER 1 ADDRESS: Phone 11:CC ( 205) 2y4 _7114
<br /> � teria:ycle , Inc . F1 Tris is a Through Shipment Applicable Permit Numbers:
<br /> 7075 R A Dtidgeford Rd . TS/OST 80
<br /> Stockton , CA 95206
<br /> CL TRANSPORTER CE FICATiOUTI
<br /> ipt of medical waste as descr
<br /> Pdnt/iype Name QR 4 Signature 1 �+"f �ajs �✓ l "L
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone Y:
<br /> a � Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> PrinViype Name Signature Date
<br /> e. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N.
<br /> Applicable Parrnit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of edbal waste as described above.
<br /> Prin*pe Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> a 400
<br /> �. eA. Daalgnated FaciOty: 86. Altamato Fao6ky: SC. AKwno% Foclitty: aD. Altwnato Faaiity:
<br /> J tedcycle , Inc . (Autoclave) Stericycle , Inc , (Autoclave) Stericycle , Inc . (Autoolave) C:nvanta Marlon , lnv
<br /> a 7875 R A BriR 1551 Shelton Drive 2775 E , 26th St , 4850 Brooklake Road i�lE
<br /> Stockton , CAy Hollister, CA 96028 Vernon , CA 90059 Brooks, OR 97305
<br /> (209 )254 -�r114 ($ 48 ) 783-7422 (98B )793-7422 (505 )393-08!30
<br /> pr rv� rf 8 152023 rsfcsT �3 Perrrnit # 864
<br /> it TREATMENT F LI�1l: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the at 9t11111M wastes In accordance with the requirement outlined In that authorization,
<br /> PrinVType Name Signature Date
<br /> ORIGINAL
<br />
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