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• — MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stericycle` IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800424$300 STANDARD MANIFEST 001 •03.21 •NOCA
<br /> • R01I 706 - 13 CUSTOMER No. 21132 N•1DTit001A; J
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> AlDI lyric Crowley � I � 1 i � L3� a l l"I I [I
<br /> •ralti><ev ui ��t~�r �� 1 �, _ ��4V: �IA IP2016
<br /> 312 S FAIRI> IONT AVE 1 /12VN23
<br /> t_ODIP CAo5 �ao-3040 ( 209) 361-1 - 5LYell o
<br /> CUSTOMER NUMBER GENERATOR'S REotaTRATIM 0
<br /> MEN
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO. OF 2D. VOLUME
<br /> CONTAIN
<br /> UN3291 Regulated Medical Waste, n.o.s., TH43 ( Bio ) TP43( Pa ) TCr13 ( Ch ) TX4 ,s( Ph )_ _ 4 ._. oa1"� rl . , 1 d
<br /> 62, PGIi — ✓D Cu Fit
<br /> UN3291 Regulated Medical Waste, n.D.S., T I ' '1 ( Blo )_____ 1 P31 (P a )_ �T C31 (Ch )� TX3 '1 (Pl i ),_,• 31 GaITU-)( d , I
<br /> 6.2, PGIi Cu Ft.
<br /> CC UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.2, PGIi 1: R F Pio -� ( Pharm ) Col-rttuated Box (4 * cIi
<br /> Q 623PGIj Regulated Medical Waste, n.o.s., Rei: 0 ,61.10T Gaskeled Sharp Cont . { CuF•t )
<br /> CC Cu Ft.
<br /> to oft,
<br /> W UN3291 Regulated Medical Waste, n.o.s., r} I ��
<br /> MEN=
<br /> 6.2, PGR 8H AJIT ask _r t d Shat'p Cont . !, CLI
<br /> UN3291 Regulated Medical Waste, n.o.s., Cu Fk.
<br /> 6.2, PGIi Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.D.s.,
<br /> 62, PGIi 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 /> 62, PGII Cu Ft.
<br /> 3. Generstor'e Coniflcetion : of 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 conditlo r transport a g to applicable International and national oIe' governmental regulations " ,
<br /> P Nemo Signawre Date
<br /> 4. TRANSP ER 1 ADOR SS: h [1
<br /> t � I /) �jr) _711r
<br /> ` C1IG {; It' , 11C • Cl 1 i1i. iu a Tt1l'C;.It( i1 �� hIP1lltiilt LpptiblePermitNumbers:
<br /> 78, 76 R A 131•ix# OP, fol•rl RLI . 1: /ta' {- 80
<br /> CA 95206
<br /> ANNE U)
<br /> a Ca TRANSPORTER ICATION : Receipt of medical waste as dose y
<br /> ~ Print/Type Name Gd I R Signature 4: !2 L �"� Date 01 113 49
<br /> MINIMUM
<br /> S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> N
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinVType Name Signature Date
<br /> B. INTERMEDIATE HANDLER 3 ! TRANSPORTER 3 ADDRESS: Phone 0:
<br /> i
<br /> Applicable Permit Numbers:
<br /> s i INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> oft Print/rype Name Signature Date
<br /> 7. DIS.REPANCY INDICATION
<br /> Manor
<br /> SA, Daafpnated Facility; El 88. Attemab FocllRy: 8C. Aitomate Facility: 80. Aftamrta Facllky:
<br /> } "^ q rn "``" " - ` Si@rh, u"1i It1C . In _ InE'rBtCr 't _ flCtr r e t .
<br /> k •i' ( c ) p / .le , 1r,� . {Auto lav _ ) Co /anIt
<br /> ta f"laricm , Ino
<br /> Q 7° 75 R ARvj& W EAl� d . oh i') , t= vxbnro Chive :2775 Et 26th St , 4850 Brooldake Road Plir
<br /> un, tec ;xt,1rAUTQC �AVED ldnrth S - 1t i. alte , UT 84054 Vernon , CA 90054"+ Brooks, OR L17305
<br /> ( ? fl 1 )93r3 - 1171 (86l?t)7°3 -7422 (505 )303-es11 r
<br /> v;-ti ?,Ss
<br /> . TAJAN 16 2023 : - :lr�-rl4t31,1,�- ::Ib PerM81 ;!t 69ea
<br /> I aI $ . � rr_• . .
<br /> it REATMENT FACILITY: I certify 'that I ave been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> H eceivedte�bovwindioa &stes in ccordance with the requirement outlined In that authorization .
<br /> Ln
<br /> '�'"' �= +��Y Signature Dale
<br /> f:
<br /> i!
<br /> f
<br />[E
<br /> ORIGINAL
<br />
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