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MEDICAL WASTE TRACKING FORM NUMBER
<br /> i� Stericycles W CASE OF EMERGENCY CONTACT: CHEMTREC 14= 42493OO STANDARD MANIFEST 001 &03.21 •NOCA
<br /> Route g: 703 - 10 CUSTOMER NO. 21132 MDTKO01902
<br /> 1 . Generator's Name, Address and Telephone Number
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<br /> aTEric Gr� iff fI I f f f f f ff 1 f 4L ; f o f f ►ff f
<br /> TO1;AY DL7Al.Y SIL- G�k'VI� 1 'TA #2016
<br /> 312 S FAiRMONT 4Vr 1 /21/2023
<br /> L OD1 , CA95240- 3840 ( 200) 36M4, 1 w
<br /> X05330 ; - G01
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRA" If
<br /> 2A. DESCRIPTION OF WASTE 2e9 CONTAINER TYPE 2C, NO, OF 20. VOLUME
<br /> UN32911 Regulated Medical Waste, n.o,s., T413( eiD )� T PG ( Pa ) TCQ3( Ch ) TXA3( Ph ) I �1C; a1 ( � 5 Cu Ft.
<br /> UN3291 Regulated Medical Waste, n ,o.s. , T Hai ( Pio )_ TP31 (Pa )_ T N31 (Ch �_ _ X31 ( Ph ) 91Ga1 ' ) ( 4 .
<br /> 62, PGI � . ,
<br /> CU Ft,
<br /> 623PG1� Regulated Medical Wastes n.o.s„ 1{ 1: ( Bio ) PX ( Ph3l-nl ) CorrugatedBox ( 43 )
<br /> Cu F6
<br /> g 623PGI� Regulated Medical Waste, n.o,s„ P 3A /OTGa _I! etedSharpCant . ( CuPt ) Cu Ft
<br /> W UN3291 Regulated Medical Waste, n.a.s„
<br /> W62, PGI ' rqL/� I r% a5ket_d 5iiaiCont . CUFt
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<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s„
<br /> 6.2, Poll Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 642, Poll 1 Cu Ft,
<br /> UN3291 Regulated Medical Waste, mo.s.,
<br /> 6.21 Poll Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.2, Poll
<br /> Cu FI
<br /> 3. Generator's Certification; "I hereby declare that the contents of this consignment are fully and accurately TOTALS loor Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/plecarded, and
<br /> are in all respects In proper condition for transport according to applicable international and national govemmental regulations " j
<br /> PrIntedlyped Name nhN, SI nature Date
<br /> cc CTRANSPORTER i ADDRESS: Phone N; ( 209) 29114 .1 jet
<br /> ctet'ic�7tLe , 11� c . THIS is,, u TfIn71.1g11 Shipment Applicable Permit Numbers:
<br /> 7075 R A Dridgeford Rc1 . T!1/0S -i480
<br /> S Slocktun , CA 95206
<br /> d tZ4 TRANSPORTER C`---E!ltRTII,FICATION: Recei toff medical waste as described ve. /�//�� �r►f,I���,� /�
<br /> ~ Print/Type Name �/ w �a 1 ` Signature tLl' r ' ` 1 `�-s+ tea.... . . Date V 63 ) , 22.
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> a � Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipi of medical waste as described above.
<br /> Printrrype Name Signature Date
<br /> B. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS; Phone M:
<br /> Applicable Permit Numbera:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION ' Receipt of lcal waste as described above.
<br /> x
<br /> Prtnt/iype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> BA. Designated Facllhy; M 09. Akems% Facility; n 8C. Atbmee Faclllly: BD, Altemate Facility:
<br /> Steric:yol:� AtI nclave ) Sterioyaia , Iris . (inc'inerator) ='tericyole , Ir+o. (Autoclave ) Covanta kl2rion , ( no
<br /> P At gid . nU Pl . FDrbnra C1rifN 27 `lfi E~ . '/. hth �t, n >;50 Sroohialco Fond NE
<br /> 'Sto �l;ton , s� 62 n 111) ah ' air l alae , u l 04051 Vernon , Gla 911060 Droolts , OR (=17308
<br /> (202 ) 20 "1414 ( � t ) sw� - 1471 ( fia ) 7 �- 74 � � (606 ) 393 t�s9a
<br /> dd �,* RWST-- ++7 yf1- 1if+IJf1-35 F'crrrit143epl
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<br /> IX TTMENT�p�Y: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have
<br /> h r d the a__bo^v�-e''i'n�alcaled wastes in accordance with the requirement outlined in that authorization .
<br /> O PrinUType Name , Signature Date '
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<br /> ORIGINAL
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