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MEDICAL, WASTE TRACKING FORM NUMBER
<br /> Oi s* Stericycleo IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .600-424-9300 STANDARD MANIFEST 001 .03.21 •NOCA
<br /> IZtlule #. 706 . 1 CUSTOMER NO. 21132 MDTKO019FH
<br /> 1 . Generator's Name, Address and Telephone Numberoil
<br /> l
<br /> !Y i' f's : Eric is t � Df-1 e
<br /> - �� K '� C1II', I»'f � I .z - L�f��1lI
<br /> I' i'A x21016
<br /> 312 `i FAIRMONT AVF I /6/2023
<br /> LORI , CA95210- 33111. 0 ( 209 ) 3 Ga- 5-1I S
<br /> V IJLi�i3 � 3- V0 1
<br /> CuEtoveR NuMeER Qtt/tERAT4H'e RE6teTRA110N 4
<br /> 2A. DESCRIPTION OF WASTE 26. CONTAINER TYPE 2C. No. OF 20, VOLUME
<br /> UN3291 Regulated Medical Waste, mo.S., 1, n P4 ., . _ n r , 0 2 CONTAIN r ` Cu Ft
<br /> 6,21 PGII 3' F , i _ (I✓ ia )_ _ Trt � ( fa ) � T TC6, 3 ( 01i ) TX<1 :_ ( F'f; ) wI ''; C� al1 { ? .. , l
<br /> UN3291 Regulated Medical Waste, n .o.s„ a ___ Tf " 1 a al; _T ; 1 f1 � 1C� ,, f f t : 1 �
<br /> 6.2, PGII ( ) ( ( —.— (—, )-- Cu Ft.
<br /> OUN3291 Regulated Medical Waste, n.o•s., „ � -,• ,
<br /> 642, PGII ( bre ) Rf: (,I'llarr, Cori�_1 £!cited Eo :c (d . :• ) Cu Ft.
<br /> QUN3291 Regulated Medical Waste, n.o.s. , 1. _. / i i r
<br /> R 6,2, PGII R J . � , kLK)T � a _ 'teeted S11 aip C_': ent . ( CuFt ) Cu Ft
<br /> W UN3291 Regulated Medical Waste, n.o•S• , . a
<br /> tZ 6.21 PGII '; #-i CgAl r,(� T Gaslceteu Sharp Cont . ( CuFt ) ou Ft.
<br /> 8 UN329i ,Regulated Medical Waste, n.o.s., Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o•S.,
<br /> 6.2, PGit Cu Ft.
<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 Ft.
<br /> 3, Generator's Certification : "i hereby declare that the contents of this consignment are fully and accurateltyy TOTALS 110� 6Cu Ft.
<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 tran accordln to applicable interrnaatitional and national governmental re I�
<br /> Print Nemo � ' + nature Date +
<br /> 4. TRANSPORTER 1 ADDRESS: V Phone ll: ( 209) 7274- 711T
<br /> st; t7GyCI �' , It3r . I Iil0 I `', e4 TIi160llgIl -`. Hj1111a It Appiicabie Permit Numbers:
<br /> 7137 .".3 R A CJddq ford Rd TS/OSJ80
<br /> �j Stoo(RI(II1 , CA 95406
<br /> R Q¢ TRANSPORTER CERTIFICATION cot of medical waste as descd
<br /> ~ Print/rype Name . �) Signature � �GG�/! /! i—` Date 1 ') 6
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone 11:
<br /> a Applicable Permit Numbers.
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M:
<br /> au{ Applicable Permit Numbera:
<br /> Z INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> I =
<br /> Pdnt/Type Name Signature Date
<br /> I 7. DISCREPANCY INDICATION
<br /> i
<br /> i
<br /> BA. Oesl9neted Fecllky: F1 tie, Akernstt Facility: n 8C. AlUmata FacI1Ny: 6D. Atbmats Fecllity:
<br /> StericyGIJOSEI)I, v�•� is /r) Steds e-lon , Inc• . (incinerater) `StericyCfe , lnr . (J%1Jta .:lave) Covanta t. t rfon , Irr:,
<br /> a 7875 Rte, i. I r } f rcl Pd 90 W . Foxboro Drive 2775 I= , 26th St , 4800 Brclokl ;l to Pncad 111
<br /> LL 7 �� - J, . F 1f, F, , ti " F,
<br /> �i ; Lao „tc� n 1='r lah Ur f�Jarth S � 1tL �f; e , �1T . •l ��.r� l �� rnc� n , C�i, IOr� � 3 C3r�., wlts , t�-1�; 97 '�u •_
<br /> gr1ca ) 29;lANi0 2023 (801 )912F.. •JX71 (806 )753-7422 (5a5 )^_, 08- 11090
<br /> ` ?IUST 80 a A4811.?- 8o Ferigt* ? 3611
<br /> BiAw
<br /> TR ENT AGILITY: I certity that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> reC the above Indicated wastes in accordance with the requirement outlined In that authorization.
<br /> Print/Pips Name Signature Date
<br /> EEE
<br /> E'
<br /> ORIGINAL
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