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MEDICAL WASTE TRACKING FORM NUMBER
<br /> i� Stericycle° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -800.424.9300 STANDARD MANIIPEST 001 .03.21 *N0CA
<br /> • ROL110 IF 71113 - 11 CUSTOMER NO. 21132 4i!i1)TIS0003/ 1 .
<br /> 1 . Generator's Name, Address and Telephone Number
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<br /> �1TTN : Eric Cl6orl; 1 �0V � It i it II5I r, N ;, ii i1 ; ; { � { i i ,i � � :.i ' k , .
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<br /> 3 i -2 S 117AIRiv10NTAVE 114 /42022
<br /> LOU ! 1=;1; 11 ' ?-t (1 - '� CIAD ( 209) 369,o `i-1 13
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<br /> CUSTOMER NUMBER GD533D0 a I GENERATOR'S AEri1STpAT1ON #
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO, OF 2D. VOLUME
<br /> _ _CONTJINE S
<br /> UN3291 Regulated Medical Waste, n.o,s., TFC -14i (Bio )_� i ,r` i i { Fnt„ )� _ i `( 1d - { in " in ? i a10 )_�_ 41 el C" r4I , TLIE� t � . � ��1_I t ) Cu FL
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<br /> W UN3291 Regulated Medical Waste, n.o.s.,
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<br /> UN3291 Regulated Medical Waste, moos.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.s. ,
<br /> 6,21 PGII Cu Ft.
<br /> 3. Generator's Certification : "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► Ili 1192 . Cu Ftt
<br /> i described above by the proper shipping name, and are ciassitied, packaged, marked and labelled/placarded, and
<br /> I are in all respects in proper condition for transport according to applicable international and national governmental regulations:'
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<br /> Printpyped Name /l' a4-oil, Signature Date
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<br /> 4, TRANSPORTER 1 ADDRESS: U Phone #:( 2G) � U11 -7 •( A
<br /> wE.11clicyclo , IlIcIr � This i ;; U 1111401olgil ` illi1) it10lost Applicable Permit Numbers:
<br /> 78175 R 1k Staidgeford Rd .
<br /> M11111IL `; triciclon , Cit 95206
<br /> CL N TRANSPORTER CERTIFICATION : Recelpt of medical waste as descri (/LI��11�ve. /',
<br /> Print/Type Name k�l � {{. Signature 0
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> E1Applicable Permit Numbers:
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<br /> 2 1 INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br /> Awn Print/TypeName Signature Date
<br /> S. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
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<br /> _a w Applicable Permit Numbers:
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<br /> z INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Recoipt of medical waste as described above.
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<br /> 7. DISCREPANCY INDICATION
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<br /> i 8A. Designated Faslil } CQ as[ylfle ,
<br /> Attemate Facility: SC. Altemste Facility: ❑ 8D. ANemate Facility:
<br /> A Swrisyc-le , 11104 :� .t �L�t1Z % ` ) teri Inc.* . ( Incin•jratc'r) Stericya he , Inc , (Aut'7clave) Co-vants f0arion , Int
<br /> w 18 ! '; RA Fir t NX ytr� 02G 9 N Foxboro Drive :j ;+ 75 E: . '26th St , 4850 Rrooklake Road NE C A Y,20u f'1 ,� r 1 S 31[ Lah° , UT (14064 Vornon , �::, 1,111058 Drool: , OR 07 06
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<br /> i w 0' ) 20lo, 71t •] P01 , . a0 - , 171 (o £� r )78ti - r i2
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<br /> it TREATME-NT-FACILIPI -.Lcog been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F” I received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type Name Signature Date
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