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MEDICAL WASTE TRACKING FORM NUMBER
<br /> i� Stencycle` IN CASE OF EMERGENCY CONTACT: CHEMTREC 141004249300 STANDARD MANIFEST 001 .03.211 •NOCA
<br /> Route * 706Z13 CUSTOMER NO. 21132 MDTKO01CAF
<br /> I . Generator's Name, Address and Telephone Number
<br /> ATEric Crowley
<br /> DI
<br /> TQKAY DlALYS ! ';•-DAViTA #;~2016
<br /> 3 .12 S FAIRMONTAVE 2/3/2023
<br /> LODI , CA95240- 3+04D ( 209) 369-5418
<br /> CuaTOIAER NUMBER 6053303- 001 GENERATOR'S REelSTRA110N N
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C, NO. OF 2D, VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., TH4 i( Pitt ) TP43( F'a ) TC43( Ch ) T,KQ3{ Phj a8'a
<br /> Cu Ft.
<br /> 623 PGII Regulated Medical Waste, n,o.s., THSI ( Blo ) 1P31 (Pa) TC31 (Ch ) TX31 (Ph ). 31Ga1T (4 . V
<br /> Cu Ft.
<br /> C 6U232291t Regulated Medical Waste, n,o.s., KP o PGII ( Bio ) RX ( (harm ) Corrugated Box (4 . 3 ) cu Ft.
<br /> UN3291Regulated Medical Waste, n.os•, R X as
<br /> GALIQT Gketed Shat Ct .
<br /> 6.2, PGII Sharp ( CUFt ) Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n .0.s. ,
<br /> W
<br /> 6.2, PGII SH GALIQT Gasketed Sharp Cont , ( CuFt ) Cu Ft.
<br /> UN329i Regulated Medical Waste, n•o.s•,
<br /> 6.2, Poll Cu Ft.
<br /> UN329i 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, PGI ) u Ft.
<br /> 3. Gerterator's Certification ; "I hereby declare that the contents of this consignment are fully and accurately TOTALS 1► � � Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and �eoeeeeeo
<br /> are in all respects in proper condition for transport according to applicable International and national governmental rag tions."
<br /> Print m
<br /> NaeidlSI tura
<br /> 4. TRANSPORTER 1 ADDRESS: 000Phone M: ( 209) 291-71114
<br /> tr Stericycle , Inc . Q This is a Through Ship nt Applicable Permit Numbers:
<br /> 7575 R A 8ridgeforcl Rd . TS/OST SO
<br /> S Stockton, OA 95206
<br /> 0c
<br /> TRANSPORTER
<br /> �, CEEvRTIT� IFICATI Receipt of medical waste as described abov
<br /> ~ Printnype Name t-.-FP' X till Signature Date 0., ��
<br /> owleft 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Pfwne M:
<br /> N
<br /> Applicable Permit Numbers:
<br /> I
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrinUrype Name Signature Date •
<br /> I
<br /> M 8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS; Phone M;
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />{ PrinVType Name Signature Date
<br /> I
<br /> 7. DISCREPANCY INDICATION
<br /> i
<br /> NU
<br /> Daolgnetod Facility: 88. AitMwte Facility$ SC. At6r rnata Facility: 8D. Alternate Fatuity:
<br /> tericycle , Inc . (Autoclave) Sterioycle , Inc . (Autoclave) Stericycie , Inc . (Autoclave) Coy+ante Marion , Inc
<br /> a 7875 R A 133 1551 Shelton Wye 2775 E . 26th St, 4850 Brcoklake Road IVF
<br /> Stockton , CA 11 IX HoIll ster, CA 95023 Vernon , CA 00058 Brooks, OR 97305
<br /> Lu (209)2944114 (866 )783-7422 (866 )783 -7422 (305 )393-0890
<br /> d TSIOST 80FEB 0 6 2023 TS/c)ST= 83 Permit # 304
<br /> W TREATMENT FA ity that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have
<br /> r received the above ndSates in accordance with the requirement outlined in that authorization .
<br /> PdnMpe Name Signature Date
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<br /> ORIGINAL.
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