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MEDICAL WASTE TRACKING FORM NUMBER
<br /> i� StericycW IN CASE OF EMERGENCY CONTACT: CHEMTREC 14804249300 STANDARD MANIFEST001 .03.21 •NOCA
<br /> RGi. e *f#: 70 . 11 CUSTOMER N0. 21132 i1j1DTK001AFV
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> J, TTN : Ejoic Crodl�y
<br /> TC� KA DIALYSIS
<br /> CI;MTP{ �#:� U1U
<br /> 31rr? S FAIRl1iON T AVE 1117/2073
<br /> LODi ) CAU5240( 3440 ( 700) 3GMt, 1E
<br /> CUSTOMER NUMBER G 053. 31 03 ` 001 GENERATOR'S REGISTRAMN M
<br /> 2A. DESCRIPTION OF WASTE 288 CON'TAINERTYPE 2C. NO, OF 210i. VOLUME
<br /> UN3291 Regulated Medical Waste, n,o,s., , CONTAIN
<br /> 6R, PGII THa"; ( Bio ) TRda( f a ) TC43 ( Ch ) T ,< 43 ( Ph ) 12*4n1T' . ( j . lc 6+ d cu Ft.
<br /> UN3291 Regulated Medical Waste, n.ox., T 1231 Ei o i P31 P I G3 C { t TX3 '1 E✓h _ 31 G IT! Q . 1
<br /> 6.2, PGII ( )_ .._._........T ( ) _ _ 1 ( .� ).—....____ ( )._ ( Cu FL
<br /> 0 62, PGIj 329Regulated Medical Waste, n,o,s., i; R ( 8io ) RX ( Phartort ) Corrugated Box (1.1 . 2w ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,os., v r LKIT sk ted Sh arp C ont . ( u >^t l Cu Ft,
<br /> 62, PGII �: " � ,� h � '� a � � r:-
<br /> W UN3291 Regulated Medical Waste, n,o,s„
<br /> W 6.21 PGII SH GAUIDT Ga _koted Sharp taint , ( CuCt ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s„
<br /> 6,2, PGII Cu FL
<br /> UN3291 Regulated Medical Waste, n,o,s,, Cu Ft.
<br /> 6.2, PGII
<br /> UN3291 , Regulated Medical Waste, n,o.s„
<br /> 62 , PGII Cu Ft .
<br /> UN3291 Regulated Medical Waste, n,o.s„
<br /> 6.21 PG11 u Ft.
<br /> 3. Generstor's Certification* "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► Cu 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 cond t rr {transport a r g to applicable international and national governmental regulations." t i�
<br /> PrIntedifTyped Name " v nature P Date
<br /> C TRANSPORTER 1 ADDRESS: hone M ; ( 0 ) [, _ _7 '] 1c1
<br /> stericycle , 1110I lllu' la ;1 Through `afliJ� ltl t1f Applicable Permit Numbers;
<br /> 78753 R A 1:�fidglJOrd f� r.I . T";/ ZIST� 80
<br /> Slockkill , CA 95206
<br /> TRANSPORTERCE FICATION: Receipt of medical waste as described Rhome
<br /> 1r
<br /> Print(type Name � � l Signature 2 Date
<br /> 5, INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; Phone tf:
<br /> N � Applkable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/type Name Signature Date
<br /> r, 8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N;
<br /> Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Pdnt/rype Name . Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> MIN� L��-I.S, Attemata FscIINy: SC, Akamata FscIIHy: $0. Akamsta Facility;
<br /> Aerlcycl; In ��qq�, :[fl j'Gi? , 1r1C . (t�UtCGinVn) fC'fl[�jr,='12 , Inc , (;�UtOCic+`/8� 4 -t lat �tct Ii3fI0i1 , ir1C
<br /> AGTOCIXV 1)
<br /> 4 781ci_ j A Bridger+gra Rd . 1 351 Shelton Chive ;, 775 E . 26th St, 4860 BroolrlakP Poad NE
<br /> LL at4Lf,;1, n , �' a S 1 p F olli �_ r, Ck\ 0502 _ \/ ? rnjon , Cl,\ 00058 t3raolr , OR g70Q5
<br /> (200 2)��1 . dAN 1 20Z� ( 86 )783-7112 '2 {$ @f3 )7�'3_'t'r122 {50r1 ) 9 ; • rs3gp
<br /> Q
<br /> Q T EATM�� sfratjhaa been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> H r ordance with the requirement outlined In that authorization.
<br /> PrinVrype Name Signature Dale
<br /> ORiGINAL
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