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MEDICAL WASTE TRACKING t' UHM NUMt3tH
<br /> I $ e0 1
<br /> Stericycle� IN CASE OF EMERGENCY CONTACT: CHEMTREC .80D A2414300 STANDARD MANIFEST 001 •03.2i •N00A
<br /> Route 4t 706 - 17 CUSTOMER NO* 21132 MM000CT6
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> TOKALY DIAL.YSISIDAVITA 72019
<br /> 312 S FAIRMONTAVE 2/11 /2022
<br /> LORI , DA95240-3040 ( 209) 369vv5418
<br /> 6033173-001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION 1f
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<br /> 2A, DESCRIPTION OF WASTE 28, CONTAINER TYPE 2C. Non OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o,s„ , CONTAINER
<br /> 6.2, PGIi TB TP14 -(Piatn ) TY1Q -( incinerate ) 44 Cal . Tui? ( . 9Cuftj cu Ft.
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<br /> 623PGIiRegulatedMedicalWasta, n.o.s„ TB2 .1 - (Bio ) ,_ TP15-(Path )_ TY15-(Chemo )____. 20 Cal . Tuts (2 7 Cuft . )
<br /> Cu Ft.
<br /> 0 823Regulated Medical Waste, n.o,s„
<br /> p PGI( TB47- (Bio ) TY4g-(Chemo ) � T149-( lnrineratej 37 Gal . Tu (Q .9 Cult. )
<br /> Cu Ft,
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<br /> 62329111 RegWated Medlcai Waste, n,o.s„ M4 348io ) • CW 3 (Chernaj VJ}CQ 0-( Phami ) 43 Gal , Tu ( 5 . 7Cuft . )
<br /> � Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s.,
<br /> W 6,21 130111KR (Bio ) Cal . Corrugated Box (4 . 32 Cuffs ) Cu Ft.
<br /> ti 823291, Regulated Medical Waste, n.o.s.,
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s„
<br /> 612, PGIi Cu Ft.
<br /> I,I Regulated Medical Waste, n.o,s.,
<br /> 6.2, PGf( Cu Fib
<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGiI Ou Ft.
<br /> 3. Generator's Certificatlon: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► 3S. 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 to applicable international and national governmental regulations,"IN
<br /> XPrintgolyped Name Signature Date NEW
<br /> 4* TRANSPORTER I ADDRESS: Phone ff: ( 209) 294_7 .114
<br /> Sterlcycle , Inc . Q This IS a Through �tll)7irjwrtt Applicable Permit Numbers:
<br /> < 0 7675 R A Bridgeford Rd . TS3/0So 80
<br /> M N Stockton , CA 95206
<br /> CC Q TRANSPORTS TIFICATI � . Rdcelpt of medical waste as described ve,
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<br /> ~ Print/TypeName Unn t `� Signature %� �''T (J►�L .»-' " --� Date >{ �
<br /> S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone fl:
<br /> Nrz Applicable Permit Numbers:
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<br /> Ec INTER MMATE HANDLER ! TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrfnMpe Name Signature Date
<br /> 6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone 1f:
<br /> x Applicable Permit Numbers.
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<br /> a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
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<br /> PrinVType Name Signature Date
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<br /> 7. DISCREPANCY INDICATION
<br /> rTAop F II 88. Alternate Facllltyt ❑ 8C. Alternate Facility: ❑ 8D, Alternate Faciltty:
<br /> � � ) teric� r OWNs - ncya e , nu. c /ole , Inc . (Incinerator) Stericycle , Inc , (Autoolave) Covanta Marion, Ino
<br /> f, 1 7875 R (.*�idlp( c . 90 id . Foxboro Drive 2775 E . 213th St, 4860 8rao44ake Road NEIf Stookton , A 0 North Salt Lame , UT 84054 Vernon , CA 90058 Brooks, OR 07306
<br /> i (2091294 -7 `114 (801 )936- 1171 (866)783-7422 (505)393- 0890
<br /> f 3 - TS/`� 'r ac+aee.redrp 3A-448/JAmv80 FerrgHt # 364
<br /> :�cagiiy-t
<br /> Ihat ' , have been authorized by the applicable 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 Data
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<br /> ORIGINAL
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