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MEDICAL WASTE TRACKING FORM NUMBER —
<br /> i� Stericyclem IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .800.424-9300 STANDARD MANIFEST 001 .03.21 •NOCA
<br /> ' Route # 703 _ 19 CUSTOMER N0. 21132 MDTKOOOBOG
<br /> 1 . Generator's Name, Address and Telephone Number {{ }} ! { ! f I
<br /> ATM
<br /> DIA Erie Crowley
<br /> TOKAY DIALYSIS-DAWITA #2016
<br /> 312 S FAIRMONTAVE 2/1 /7022
<br /> LOR11 , CA 95240-3840 ( 2019) 369-54 ') 8
<br /> I r� �]
<br /> CUSTOMER NUMBER � Q�3v03- 1� � 1 GENERAToRlsREGISTRATIONN
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINERTYPE 2C. NO, OF 20. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., CONTAIt) , +
<br /> 6,2, PGII TB '14 -(Bio ) TPW(Path) N '14-( Incinerate ) 44 Cal . Tub , 9Cul1 ry cu Ft.
<br /> 62apa
<br /> ll Regulated Medical Waste,
<br /> n,o.s„ TB21 (Bio ) TP16- (Path ). _ TY15-(Chemo ) 20 Gal . Tub (2 7 Cuft . ) Cu Ft.
<br /> 0 623P61IRegulated MadicaiWaste, n.o,s„ T1349- (Bio ) TY49- (Chema ) T149-(Incinerate ) 37 Gal . Tu (4 .9 Cult. )
<br /> Cu Flo
<br /> a 623PGlIRepulaledMedlcalWaste, n.o,s,, WI348 { Bi0 ) C\/AS3 (Chemo )_„__.•_WX43-( Phann ) 43 Cal . TU ) ( v .7Cut't . )
<br /> Cr Cu Ft.
<br /> W UN3291 , Regulated Medical Waste, n,o.s.,
<br /> 1Z 6.2 , PGII Kid (Bic ) Gal . Corrugated Box. (4 . 32 Cuff. ) Cu Ft.
<br /> UN3291 , Regulated Medical Waste, mu., �� Q
<br /> 6.21 PGII e • Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s„
<br /> 6.2, PGII Cu Ft.
<br /> 642,
<br /> UN3291
<br /> 911 Regulated Medical Waste, n.o,s,, Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.s,, Cu Ft.
<br /> 6.2, PGII
<br /> 3. Generator's Certification: 01 hereby declare that the contents of this consignment are fully and accurately TOTALS ` O � 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 condition for transp ccording to applicable International and national governmental regulations" /f
<br /> Prihtedrryped Name Signature Date
<br /> 4. TRANSPORTER I ADDRESS: Phone #:( 209) 2944114
<br /> w SteriCycle , Inc . This is a Through Shipment Applicable Permit Numbers:
<br /> a 7575 R A 13ridgeford Rd . TS/OST 80
<br /> (n Stockton , CA 95206
<br /> as Q TRANSPORTER` CERTIFICATI : Receipt of medical waste as descri trove,
<br /> Printlrype Name )Oat, �b' I Anilll Date � 10169,
<br /> 5, INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> N
<br /> Applicable Permit Numbers:
<br /> 6c INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Pdnt/T a Name Signature Date
<br /> � YP 9
<br /> „ 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> 4 w
<br /> Applicable Permit Numbers:
<br /> 2 INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> $ _
<br /> — PdnMpe Name Signature Date
<br /> 7. DISCRI~PANCY INDICATION
<br /> 666 MAYRA
<br /> WtL8A(.r R`t�9 'p EZ 8a. Alternate Facility: 8C. Altemate Facility: 80, Alternate Facility:
<br /> eyc (Autoclave) tericycle , Inc . (incinerator) Stericycle , Inc . (Autoolave) Covanta Marion , Inc
<br /> 5M Q N . Foxboro Grine 2776 . 28th St, 4 $50 6rooklake Road NE
<br /> 1 7 87 6 R 4F EBdlftf
<br /> 11 Stockton , CA 96208 orth Salt Lake , UT 84054 Vernon, CA 90058 Brooks, OR 97306
<br /> w (209 )294-7114 01 )930 - 11711 (860 )783-7422 (506 )393 -089n
<br /> TS109KV#v4 cKac�cdt� A-4481JA-36 Pertrit0 364
<br /> a
<br /> t! NT' : I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F received the above indicated wastes In accordance with the requirement outlined in that authorization .
<br /> PrInMpe Name Signature Date
<br /> ORIGINAL
<br /> I `
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