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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stencyclea IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -BDW424-9300 STANDARD MANIFESTOoi •o3.2t -NOCA
<br /> 7 (•Milk) !J: 706 - 1 7 CUSTOMER NO, 21132 MDT11d%= () 9D3
<br /> 1 . Generator's Name, Address and Telephone Number
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<br /> i 11 a FA 11 % IN] 0 Nl A IF 1 /7/2022
<br /> I _ OOD11 CA 95240 - 3ut1 G ( 209) s 69- "11. 1 u
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION N
<br /> 2A. DESCRIPTION OF WASTE 219, CONTAINERTYPE 20. Nos OF 2D. VOLUME
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<br /> 3. Generator's Certification ; "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► Cu Fto
<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 a ording to applicable international and national governmental regulatlons"
<br /> Print Name 4.� signature pate,oloo
<br /> 4. TRANSPORTER 1 ADDRESS; J''""j Phoneff;! ! tJ� } ;� �:1 _ .1 .1 , 1
<br /> �ituldoyde , Inc . U `1 . 1tia is t: Tl rot-10 l3111jxt I 'L Applicable Permit Numbers
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<br /> flows
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<br /> a TRANSPORTER CtEtRTIFICA/TytON : Receipt of medical waste as described ve/. `
<br /> Print/type Name V Q L►J � Signature w"ti Dale i 6
<br /> S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone
<br /> Applicable Permit Numbers
<br /> 9 lag g INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> PrinVIl Name Signature Date
<br /> M 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N.
<br /> �i Applicable Permit Numbers:
<br /> aso R INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> — PrinVType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> i
<br /> BA. Designated Facll : lternate Facility: E] 8C. Alternate Facility: 8D. Altemete Facility:
<br /> c _r: cycie , RYrAN = ELSE r• terit cle , Inc . ' Incin_• ratc� rj Stericycle , [ Fie. (AutorlB4l C olil to i1,iarion , Irnv
<br /> a '.! 17n F; A BndyeGoo NEA 90 NO = oxboro Dritle 2775 E . '16th St 4150 Broolclalte [Road HIE
<br /> cite,; ,, t: !a _., , ('! ortii �a1t L aka , Zl t +1 'aCr,4 %lerr�nn , ! ", 9r?i75G 13f�� ,71ia, rJ G7wtJ5
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<br /> At 18 2022 ( GGi ) � a- i171 ( 860 )783 . 7.};> > (SGrI3du- C132G
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<br /> IX TEATMEN ACILI pat I have een authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> t - re�ived khe in d VMStes in actor ante with the requirement outlined in that authorization.
<br /> II0 P1IrW? parNmff6 ~~ Signature Dale
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<br /> ORIGINAL
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