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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stencyil: V IN CASE OF EMERGENCY CONTACT; CHEMTREC Relit .424.9300 STANDARD MANIFESTo01 .03.21 •NOCA
<br /> i onto i:: 706 " 10 CUSTOMER N0. 21132 WIi eloI (000AIIS
<br /> 1 . Generator's Name, Address and Telephone Number k� I
<br /> ATTi\I : Eric Crowley
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<br /> TCKA"f DIALYSIS tDAVITAii2016 31, 14
<br /> 3 12 S I=AII? fv ONT /' VE IJ'trIl207. 2
<br /> 1. 01A , Cid 95240 , 38110 (209) 369w54el 0
<br /> CUSTOMER NUMBER 605330311001 GENERATOR•$ REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 20. Noe OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n,os., ( ) L1 _ ) tC0 T(A
<br /> 6.2, PGII ' i` t� t /I - Dict __ ... 1'I 1 (t �ltil 'I' `l4 .4 -{ lncjuctatc)_ _ t f� al . TtttJ � . J ttlt) L./ 7„ Cu Ft.
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<br /> 623291IRegulated Medical Waste, Riots., • l I1 `.? t -{ 13io )� � ll ' i ?i -{f� tltfl }�_' l' Y [ 5 { � ltCtllu ) _ _ _ LU i3tt ! • TO) (2 7 Ctifl .) Cu FI.
<br /> p 623 PGII Regulated Medical Waste, n.o.s., • l • 1t0 jHtC ,�� I �f,l � _ ( ItU � t IfO ( jt14tt10tialt ) — a '1 Galo '1lt i (i . 9 Cu (i . )
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<br /> 623 PGII Regulated Medical Waste, n.o.s., IUt k • { C3tu ) (;lir„I-{ClttillU )_ _ •t 'I•( 1- 11allill)-�:j3 Gtal . 'I'L) t ( 6 .70aft .) Cu FI.
<br /> Z 82RegulatedMedical Waste, Hoots.,
<br /> 1PGIj �_ _ _ {t� IU ) Gal . CoiltgLa* , d Bux (,4032 Cttft . ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, Roots.,
<br /> 6.2, PGII +( r x 2'i 3 CO- 4 , • Cu FI.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Fl.
<br /> UN32911 Regulated Medical Waste, n.o,s„
<br /> 6,21 PGII Cu Ft.
<br /> UN32911 Regulated Medical Waste, n.o.s.,
<br /> 6.21 PGII joe Cu Ft.
<br /> 3. Generator's Certification; °I hereby declare that the contents of this consignment are fully and accurately TOTALS I► LSS Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and p� proper er labelled/piacarded,
<br /> are in all respects In ro condition for transport according to applicable international and national governor nt i regulations”
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<br /> fX Printed/Typed Name /"�`�- ^"" Signature Date r 2
<br /> 4, TRANSPORTER 1 ADDRESS: Phone #;( 709) 20;1.. 1 t I �r
<br /> Stericycle , Inc . This Is U Tl11601. 14tl < flipmetit Applicable Permit Numbers:
<br /> o / 875 l•2 A Drifteford IZtt • I' tiiff:) :i 'ttowti0
<br /> Olos :9tocicloll , Cil 95206
<br /> a q TRANSPORTER r .R..TI•FICA�}ry^xp� N : Receipt of medical waste as described e,�
<br /> ~ Print/Type Name �1t� �.3� 1t � Signature (,K�'� Date d • r'^' ��
<br /> ti 6. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> pp WN cc Applicable Permit Numbers:
<br /> z � INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinUType Name Signature Date
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<br /> I e, 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> I 5 w Applicable Permit Numbers:
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<br /> a ED a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
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<br /> I — Print/Type Name Signature Date
<br /> l 7. DISCREPANCY INDICATION
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<br /> Q SA. tedNaef ; Be Alternate Facility: � L3Ct. Alternate Faculty; ED, Altemeta Facility.
<br /> l Jelement ' , tyrl ,_kAv is i indu ti{loNDr"/. ,% s ;Ldgi,_ I,? , Inc= . (incinordtor) Siteilcycl ? , Inc . (ALL iJCl ":
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