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MEDICAL WASTE TRACKING FORM NUMBER
<br /> ON. Stericyclee IN CASE OF EMERGENCY CONTACT: CHEMTREC 1400.424-9300 STANDARD MANIFEST 001 .03-21 •NOCA
<br /> Route ;11: 703 - 1 G CUSTOMER NO, 21132 MDTK00091' A
<br /> 1 . Generator's Name, Address and Telephone Number I t II ! ll
<br /> 11TTN : Cric CrOtnrif;y
<br /> TOKAY DiRLYSI S- DAVITA 1142016
<br /> 312 S FIIiWONT AVE 1 /111112022
<br /> LODI , CA 952 ,10-38x' 0 (209) 3694• 5118
<br /> 6053303- 00 '1
<br /> " CUSTOMER NUMBER GENERATOR'S REGISTRATION M
<br /> 2A. DESCRIPTION OF WASTE 29. CONTAINER TYPE 2C4 NO, OF 209 VOLUME
<br /> UN3291 Reguiaietl Medical Waste, n,os„ t t11DNTA1NER
<br /> 6,2, PGII I' L31r, } f`tatA�-( i �IiII } I ! 1 � -tl ► tcil � ctaty ) 4 f � al . ' I'ub , � l3Ctftt) . Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n,o.s„ ' i' I321 -(I� Iu }��'!' I � t a - l' :tilt __ __�f' Y l J • irjttict _, 20 Cal . 't'ub 2 7 Ctitt .
<br /> 6,2, PGII ) Cl
<br /> { ) ) Cu Ft.
<br /> 0 62329tPG1Regulated Medical Waste, n.o.s„ 'I� l3i � -tll } ^ t ` � - �� IlitttlU}__ __ t` I � O � ItIC11101'Et1b } 7 Gal . `t'lt I {4 .O CU1t.) Cu Ft.
<br /> &
<br /> UN3291Regulated
<br /> n
<br /> Regulated Medical Waste, .o.s, �jlll3ri 3-rittlU ) Geri �{ ({� Il �) illb}_ ( i3ltilittl} �, :� G 11 . Tu (5010till .}
<br /> Cu Ft.
<br /> tZ 623 PGII Regulated Medical Waste, n.o.s„ s� i � _ _ 4Olo } Gal . COi' ttigated box OM Clift . ) Cu Ft.
<br /> I
<br /> 6,21 2914 Regulated Medical Waste, n.o.s,, Cu Fl.
<br /> UN3291 , Regulated Medical Waste, n,o.s„
<br /> 6,21 PGII Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Fig
<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 ► 3„ 5 . Cu Ft,
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/piacarded, and
<br /> are in all respects in proper condition for transport according to applicable International and national governmental regulations "
<br /> PrIntedMiped Name Signature Date
<br /> ih
<br /> 4. TRANSPORTER 1 ADDRESS: Phone N:(2O9) 294 "71014
<br /> LU Stericycle , I11c . TRIS IS in TI1i'011911 SIA) I11e1lt Applicable Permit Numbers:
<br /> 7875 R A Bridgiaford Rd . 'I WO $, lw= 80
<br /> N Stockton , CA 95206
<br /> CL d TRANSPORTER CERTIFICATI Receipt of medical waste as described 6,74 PrinU
<br /> TypeNama �a� \ U ` b � Signature �1� jfI Date Qd ti 6. INTERMEDIATE HANDLER 2lTFtANSPORTER 2 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> `a
<br /> i INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Prini/rype Name Signature Date
<br /> M m 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> a w Applicable Permit Numbers:
<br /> W J
<br /> No INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> a s
<br /> Print/Type Name Signature Date
<br /> I 7. DISCREPANCY INDICATION
<br /> i.
<br /> 8B. Attemate Facility , 8C, Alternate Facllity: 8D, Alternate Facility:
<br /> :3i .erlcycle , hji: . (AuroyAVe) c; ' _ rlcycIc , Inc . (Indrierator) c,tenkycls , Inc . (Autoclay.:) Covanto klarlon , Inc
<br /> I a • 7075 I:HERNANDEZ 91 N , Foybt;m> DriYo:' 2775 f: , Util St , 4850 Procildalts:, goad HE
<br /> u- C; Wcktc, n , C A 0 ;1')06 N 4h Salt t-alt+_ , U{• 84054 Vernon , CA W058 Brooks, OR 07306
<br /> (200 ) 2�-43 -I -JAN 15 2022 ( E ) I )SA6 - t 171 (8136 ) 783 7422 (505 )303motal
<br /> Uj
<br /> d I' S/r�:t '1- 30 00 : x198/JA- 3S P,� rmitit 361
<br /> f w a TRE TS ify that I ave been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> tom- received the above Indicated Wastes in ccordance with the requirement outlined in that authorization,
<br /> Printrrype Name Signature Date
<br /> e
<br /> I
<br /> I ,
<br /> ORIGINAL
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