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MEDICAL WASTE TRACKING FORM NUMBER
<br /> io Ster' lcyde` IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 *SW424-9300 STANDARD MANIFEST001 .03.2f •NOCA
<br /> 7 ROLIte I 706 4 CUSTOMER NO, 211132 IVIDTOODDHY
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> TTI, : Eric . DAVIu II I II II I II I�I�I III111111111111111111 II II 111111111 IIIA
<br /> 1'C► K/�.Y GI /•1LYSI �- G/1.Vt1'!t �t'2U1 �a
<br /> 312 S FAIRMONTAVE 2/10/2022
<br /> I_Odl , CA 95240- 3040 ( 209) 369 5490
<br /> CUSTOMER N6053303=009UMaEq GENERATOR'S REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 289 CONTAINER TYPE 2C. NO. OF 2D. VOLUME
<br /> Cu
<br /> is., CONTAINER
<br /> UN3291 Regulated Medical Waste, n.o
<br /> 6.2, PGII TB14 - (Bio ) TPW( Path ) T r14 - ( incinerate ) A4 Gal . Tub . 5 . 9Cuft ) 0 . Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s., TB21 - Blo TP15- Path TY15 Chemo 20 Gal . 'tub .7 ft .
<br /> 6.2, PGII ( ) ( ) ( ) ( ) Cu Ft.
<br /> CC p b23PGiIRegulated Medical Waste, n.o.s., TE49_ (Bio ). TY40-(Chenix )_ TI40 Incinerate ) 37 Gal . TO 1 (4 . 9Cuft. ) Cu Ft.
<br /> fi 23PGII Regulated Medical Waste, n.o.s., y\/E34 341f0 ) C10A °r(Ch etrio )_ WXA 3 wlPi ,arm ) 43 Gal . TLI ( 5Cu Ft.
<br /> . 7Cuft. )
<br /> W UN32911 Regulated Medical Waste, n.o.s., � � Evia Gal . C'OPiV Glad 6OX 4 . 32 Clift.
<br /> IZ 6.2, PGII ( ) ( ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII
<br /> 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 : "1 hereby declare that the contents of this consignment are fully and accurately TOTALS � j 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 transport according t app be International and national government regulations"
<br /> Printed/Typed Name PowcV , Signature Dafe�
<br /> 4. TRANSPORrER f AbbRESS9 Phone #: (209) 2544914
<br /> Stelicycle , Inc . Tl* IS a ThroUgh Shipment Applicable Permit Numbers:
<br /> c 7 075 R A aridgeford Rd * TS/ 1ST O
<br /> 2 N Stockton , CA 9520 €
<br /> phi q TRANSPORT E`UJA FICATj7cl Receipt of medical waste as descrl I va.
<br /> ac �` 1� fj
<br /> ~ PrtnVType Name WA -1Signature bate
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Prtnt/Typs Name Signature Date
<br /> i 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> Applicable Permit Numbers:
<br /> S INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> F — Signature Date
<br /> 7, DISCREPAN i
<br /> HERNANDEZ
<br /> h}� 6A. Designated Facility: B, ABernate Facliity: [ ] BC. Akemsh Faciffty: 8D. Akamate FacllRy:
<br /> JI iteflDAfcleF&B (4402012 St ricyole , inC. (1170inerator) Stericycle , Inc . (Autoolave) C: ovanta Marlon , Ino
<br /> a 7675 R A BridgeNrd Rd. 90 iNJ , Foxboro Drive 2776 E; 20th St, 4850 Brooidake Road idE
<br /> L6 Stockton , CA 9520 Nc :h Salt Lake , UT 8404 Vernon , CA 90058 Brooks, OR 97305
<br /> w (209 )2 (6 ( 1 )936- 1171 (606 )7834122 (505 )398- 0890
<br /> as - 446iJA-38 Pe rrnit # 384
<br /> TREATMENT FACILITY: I certify that I have been authorized by the applioable state agency to accept untreated medical wastes and that I have
<br /> H received the above indicated wastes in accordance with the requirement outlined In that authorization ,
<br /> Print/Type Name Signature Date
<br /> fI
<br /> I
<br /> f
<br /> ORIGINAL
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